Flexible Approaches Needed for GLP-1 Coverage Decisions | PBMI 2025

The issues of cost, affordability and access to GLP-1 therapies to treat people with obesity will not be going away anytime soon, according to speakers during a panel of pharmacy benefit managers (PBMs) at the Pharmacy Benefit Management Institute’s annual meeting today in Orlando. The increase in demand for such therapies and the research and approval of new drugs and new indications for drugs such as Wegovy and Zepbound mean that employers, PBMs, and insurers will continue to grapple with how to offer these medications to patients.

Oron Stenesh

“GLP-1s are the ever-present conversation,” said Oron Stenesh, vice president of product at Optum Rx.

GLP-1 drugs such as Ozempic, Victoza and Mounjaro were first approved to treat patients with Type 2 diabetes. They top many trend reports as the drivers of increasing drug spending, and employer surveys also highlight the importance of managing these costs.

Mary Bellanti, RPh

But this is just the tip of the iceberg, Mary Bellanti, RPh, vice president, clinical strategy and sales at MedImpact, said during the panel discussion. “We need to be addressing the category as a whole.”

In the last few years, the class has exploded as manufacturers achieved FDA approval for weight loss, obstructive sleep apnea, and kidney disease. The FDA initially approved Wegovy (semaglutide) in 2021 for weight loss but later approved it to reduce the risk of major cardiovascular events and just recently granted accelerated approval to treat patients with metabolic dysfunction-associated steatohepatitis (MASH). Zepbound has also been approved to treat obesity and obstructive sleep apnea.

Research is continuing of GLP-1 other conditions, including age-related macular degeneration, Alzheimer's disease and obesity related mental health issues.

Panel members also agreed that all stakeholders will need to come together to provide multiple programs and approaches that meet the needs of patients and employers.

What is needed, Stenesh said, is flexibility with different solutions for different employers, who may not have the same type of patient population. “This is not a one-size-fits-all approach,” he said.

Nate Harold, Pharm.D.

A balanced and informed approach is needed, said Nate Harold, Pharm.D., chief pharmacy officer at MedOne Pharmacy Benefit Solutions. Mentioned that some of his clients have a high employee turnover and may not be interested in longer-term approaches. “Others have a longer-term approach that invests in their people.”

Harold pointed to a study done by Aon and released in the spring of 2025 that showed coverage of GLP-1 therapies for weight loss has a longer-term impact on preventing and managing chronic diseases. Aon analyzed medical and Rx claims data for more than 50 million commercially insured lives, including 139,000 prescribed GLP-1 users from 2022 to 2024.

Aon found a 7% improvement in the medical spend group for GLP-1 users in the second year, which was sustained over time. Additionally, GLP-1 users had a 44% reduction in risk of hospitalizations caused by major adverse cardiovascular events, as well as improvements in pneumonia, inflammatory bowel disease, osteoporosis, and alcohol and substance abuse.

As a result of these findings, Aon launched of its own GLP-1 weight management program for U.S. employees. The program combines access to treatment with virtual support and adherence tools.

During the session, however, Deborah Dempsey, Pharm.D., RPh, COO of ProAct, said that employers are still concerned about the impact of coverage on healthcare spending and that there needs to be a better ROI for the GLP-1 drugs to enable more employers to provide coverage for these drugs.

Although funding the high-cost obesity products such as Wegovy and Zepbound dipped for employers in the last few years, Harold believed that number will continue to rise, especially as generics and new products become available and increase competition. Recently Teva Pharmaceuticals has received FDA approval and has launched a generic version of Saxenda (liraglutide).

Additionally, Lilly’s investigational oral GLP-1 orforglipron has shown promising results in a phase 3 trial. Lilly plans to submit an application for orforglipron for obesity by the end of this year and for diabetes next year. And FDA officials are expected to make a decision about an oral formulation of Wegovy by December.