Access to GLP-1 medications can be challenging due to high costs, insurance limitations, and prior authorization requirements. This page provides an overview of resources and strategies to help patients and healthcare providers navigate the access process.
Insurance Coverage Overview
- Commercial Insurance: Most private insurers require prior authorization for GLP-1 medications. Coverage may be limited to FDA-approved indications (e.g., type 2 diabetes, obesity).
- Medicare Part D: Covers certain GLP-1 drugs for diabetes management. Coverage for weight loss medications (e.g., Saxenda, Wegovy) may be restricted.
- Medicaid: Coverage varies by state. Some Medicaid plans require BMI thresholds or comorbidity documentation.
- Affordable Care Act (ACA) Plans: May offer obesity management support but often exclude weight loss drugs from formularies.
Prior Authorization Requirements
Many insurers require documentation of:
- Diagnosis (type 2 diabetes or obesity)
- Failure or inadequate response to lifestyle modification alone
- BMI ≥30, or ≥27 with comorbidities (for weight loss meds)
- Specific lab values (HbA1c, fasting glucose, etc.)
- Previous therapies tried and failed
Prior authorization forms are typically available on the insurer’s provider portal.
Patient Assistance Programs (PAPs)
Several manufacturers offer financial assistance for eligible patients:
- Ozempic, Wegovy, Rybelsus (Novo Nordisk): [novocare.com](https://www.novocare.com)
- Saxenda (Novo Nordisk): Savings card and eligibility-based free drug program
- Trulicity (Eli Lilly): [lillycares.com](https://www.lillycares.com)
- Zepbound, Mounjaro (Eli Lilly): Access support and patient savings cards
Most programs require proof of income, insurance denial, or lack of coverage.
Tips for Providers
- Use electronic prior authorization (ePA) tools to reduce paperwork delays
- Document comorbidities and prior weight management attempts clearly
- Appeal denied claims with additional medical justification and patient impact notes
- Work with specialty pharmacies that offer navigation support
Discount Programs
- Pharmacy discount cards (e.g., GoodRx, SingleCare) may reduce out-of-pocket costs but are not usable with insurance
- Some mail-order pharmacies and savings programs offer lower cash prices for certain GLP-1 drugs
Downloadable Resources
Coming soon: Insurance appeal templates, prior authorization checklists, and patient-facing financial aid guides.
Disclaimer
Coverage policies vary by plan and location. This information is for general guidance only and should not replace insurer-specific instructions or professional billing advice.