ACCESS TO GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONIST ANTIOBESITY MEDICATIONS: FORMULARY COVERAGE AND PRIOR AUTHORIZATION RESTRICTIONS ACROSS U.S. PAYERS
Author(s)
Matthew Klebanoff, MD, MSHP1, Zhi Geng, MPH1, Pengxiang Li, PhD1, Grace Tran, PharmD2, Jalpa Doshi, PhD1;
1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA, 2Clarivate Analytics, Chandler, AZ, USA
1University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA, 2Clarivate Analytics, Chandler, AZ, USA
OBJECTIVES: Glucagon-like peptide-1 receptor agonists (GLP-1s) represent a breakthrough in obesity treatment, but their high costs have prompted payers to implement coverage restrictions. Little is known about how U.S. payers across insurance segments cover antiobesity GLP-1s. This study examined formulary coverage and prior authorization (PA) policies for antiobesity GLP-1s across commercial, Medicaid, and health insurance exchange (HIX) plans.
METHODS: We obtained 2025 data from Clarivate’s Fingertip Formulary for branded GLP-1s approved for weight loss: liraglutide, semaglutide, and tirzepatide. For a sample of plans covering these GLP-1s, we obtained PA policies and extracted clinical PA criteria (e.g., body mass index [BMI] cutoffs) and administrative criteria (e.g., documentation requirements).
RESULTS: Analysis of 3,686 plans with 214.82 million enrollees revealed substantial variation in coverage across insurance types. Among HIX enrollees, coverage was minimal (2.9-6.8% depending on the specific GLP-1), whereas up to two-thirds of enrollees in commercial plans (50.9-67.2%), Medicaid FFS (55.0-66.8%), and Medicaid MCOs (32.8-63.6%) had access to ≥1 GLP-1. Among plans providing coverage, PA was near-universal in commercial plans (90.4-93.3%), Medicaid MCOs (89.7-100%), and HIX plans (100%), but less common in Medicaid FFS (28.7-41.3%), as California lacked PA. We obtained PA policies for >70% of commercial enrollees in plans requiring PA (70.7-78.2%, depending on the GLP-1), all Medicaid FFS enrollees, and a substantial portion of Medicaid MCO enrollees (57.0-79.7%) and HIX enrollees (47.4-63.9%). PA policies were frequently more restrictive than FDA labeling. For example, 27.6-35.0% of commercial enrollees faced BMI cutoffs more stringent than FDA labeling, and 18.4-26.6% were in plans requiring ≥2 comorbidities versus the single comorbidity in FDA labeling.
CONCLUSIONS: Approximately one-third of commercial and Medicaid enrollees, and nearly all HIX enrollees, lack coverage for any antiobesity GLP-1. PA is commonly required across insurance types, with restrictions that are often more stringent than FDA label indications, which may limit appropriate patient access.
METHODS: We obtained 2025 data from Clarivate’s Fingertip Formulary for branded GLP-1s approved for weight loss: liraglutide, semaglutide, and tirzepatide. For a sample of plans covering these GLP-1s, we obtained PA policies and extracted clinical PA criteria (e.g., body mass index [BMI] cutoffs) and administrative criteria (e.g., documentation requirements).
RESULTS: Analysis of 3,686 plans with 214.82 million enrollees revealed substantial variation in coverage across insurance types. Among HIX enrollees, coverage was minimal (2.9-6.8% depending on the specific GLP-1), whereas up to two-thirds of enrollees in commercial plans (50.9-67.2%), Medicaid FFS (55.0-66.8%), and Medicaid MCOs (32.8-63.6%) had access to ≥1 GLP-1. Among plans providing coverage, PA was near-universal in commercial plans (90.4-93.3%), Medicaid MCOs (89.7-100%), and HIX plans (100%), but less common in Medicaid FFS (28.7-41.3%), as California lacked PA. We obtained PA policies for >70% of commercial enrollees in plans requiring PA (70.7-78.2%, depending on the GLP-1), all Medicaid FFS enrollees, and a substantial portion of Medicaid MCO enrollees (57.0-79.7%) and HIX enrollees (47.4-63.9%). PA policies were frequently more restrictive than FDA labeling. For example, 27.6-35.0% of commercial enrollees faced BMI cutoffs more stringent than FDA labeling, and 18.4-26.6% were in plans requiring ≥2 comorbidities versus the single comorbidity in FDA labeling.
CONCLUSIONS: Approximately one-third of commercial and Medicaid enrollees, and nearly all HIX enrollees, lack coverage for any antiobesity GLP-1. PA is commonly required across insurance types, with restrictions that are often more stringent than FDA label indications, which may limit appropriate patient access.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
HPR74
Topic
Health Policy & Regulatory
Topic Subcategory
Insurance Systems & National Health Care, Reimbursement & Access Policy
Disease
SDC: Diabetes/Endocrine/Metabolic Disorders (including obesity)