For clinicians, insurance coverage for glucagon-like peptide-1 (GLP-1) receptor agonists can feel tricky to navigate. But the key to getting coverage for your patients is by understanding which indications GLP-1s are covered for, and how your patient might fit into those different categories. Sometimes it takes digging a little deeper into alternative ways of diagnosing Type 2 diabetes or identifying a patient’s other qualifying comorbidities to improve patients’ access to these medications.
Here, we’ll discuss the lowest-lift paths to GLP-1 coverage for your patients.
Don’t stop at HbA1c if clinical suspicion is high
There are two main indications for GLP-1s: Type 2 diabetes and overweight or obesity. GLP-1s are almost universally covered for Type 2 diabetes. The most straightforward pathway to coverage for your patient is to find out whether they fit into this category.
Many clinicians rely on hemoglobin A1c (HbA1c) alone for a Type 2 diabetes diagnosis. But a fasting glucose or oral glucose tolerance test may be more useful than HbA1c to make that diagnosis. These tests are a bit more sensitive, and you may be able to diagnose some patients who don’t meet the criteria for Type 2 diabetes based on HbA1c alone.
If you’re only using HbA1c to make your diagnoses, you may be missing patients who would qualify for GLP-1s.
Know which comorbidities unlock coverage
It’s usually harder to get GLP-1s covered for overweight and obesity. One way to get around this is if patients have one or more comorbidities. These include:
Fatty liver
Obstructive sleep apnea
Cardiovascular disease
These medications have separate FDA indications for those specific comorbidities. Identifying whether your patient falls into one of those categories can be another way to unlock coverage.
Know where the coverage decision is made
Coverage isn’t always a prescribing problem, it can also be a benefits design problem. It often depends on employer-selected benefits. But patients often have more control over their benefits design than they think. You can encourage them to talk to their benefits manager for GLP-1 coverage. Advocating for themselves can go a long way.
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