Why health plans should rethink GLP-1 coverage

Every day it seems there is good news on scientific breakthroughs. The FDA approved a first-of-its-kind drug to extend the survival of those with pancreatic cancer. mRNA vaccines show promise in late-stage melanoma. AI is helping catch tumors earlier than ever. And we might only be scratching the surface of the health benefits of GLP-1s.

In this golden age of medical innovation, we could live longer, healthier lives and treat diseases that were once death sentences. Except for one thing. While miracle drugs are here, access remains frustratingly out of reach.

Obesity drugs known as GLP-1s are a prime example. Originally developed to treat diabetes, GLP-1 medications now help patients manage obesity while also improving blood sugar control and lowering the risk of heart disease. For many people, GLP-1s can improve physical health, quality of life and long-term outcomes. They've also shown promise in treating substance use disorders, potentially lowering dementia risk and even helping patients recovering from traumatic brain injuries.

Systemic barriers, however, have kept these transformative treatments out of patients' hands. Health plans keep dropping coverage of GLP-1s, despite a laundry list of health benefits they provide. Roughly one-third of commercial and Medicaid enrollees lack coverage for GLP-1s, and the criteria for coverage often change. State benefits have also been spotty. In Maine, for example, coverage of GLP-1s dropped significantly, leaving obesity patients in the lurch. Michigan has narrowed GLP-1 coverage to morbid obesity only, with strict prior authorization requirements.

As an endocrinologist, I see what these medications can do for patients. I have watched people improve their health, regain mobility and reclaim hope for the years ahead. For patients with diabetes, the cardiovascular and renal benefits have been clearly shown. Unfortunately, I have also watched them hit roadblocks that have nothing to do with medicine and everything to do with coverage.

While many people do not have access to innovative treatments like GLP-1s, those who do often encounter a maze of barriers: prior authorization, step therapy and high out-of-pocket costs. For patients, these hurdles can turn a promising treatment into an inaccessible one. These barriers make adherence difficult, forcing many to drop medications or go for long periods without a dose. Patients wait weeks, even months, to get their medication, only to lose access when the health plan changes its coverage criteria or increases patients' out-of-pocket costs.

Competition has significantly reduced GLP-1 prices, but they can still be too expensive for some patients to afford. For patients willing to go outside their health plan, direct-to-consumer options are available but can be costly. Many patients are stuck with whatever their health plans will cover — which often isn't much.

When insurers focus only on upfront costs, they miss the bigger picture. Effective obesity treatment can reduce downstream complications, improve long-term health and potentially lower spending tied to chronic disease. One study found that people between the ages of 40 and 50 using GLP-1s saved an average of $192,735 in lifetime medical bills, suggesting that coverage today could yield significant savings down the line. The benefits aren't limited to patients. Avoidable hospitalizations, surgeries and the costly progression of chronic conditions also would be significantly reduced.

It's time for health plans to consider more closely the multifaceted value that GLP-1s bring, both to payers and to the patients they serve. At a minimum, that means coverage decisions that reflect these medications' impact, not just their upfront price. It could also mean exploring a value-based approach, in which insurers align coverage and reimbursement with patient outcomes.

Without access, the promise of innovative treatments withers. Limited access also discourages innovation. And it leaves patients worse off.

Research and medical ingenuity have put miracle drugs within reach of the Americans who need them. Health plans shouldn't stand in the way.

Sethu Reddy, M.D., is an endocrinologist based in Michigan. He previously served as chair of endocrinology, diabetes and metabolism at Cleveland Clinic and is a professor and senior associate dean of research at Covenant HealthCare College of Medicine at Central Michigan University.