Insurance and GLP-1s: How to Check Your Coverage

If you’ve been taking a compounded version of a glucagon-like peptide-1 (GLP-1) medication, you’ve likely been paying for it out of pocket. However, compounded GLP-1s have largely been phased out because branded semaglutide and tirzepatide are no longer in shortage.

If you are switching to a branded GLP-1 from a compounded version, it’s helpful to know what to expect when it comes to cost and insurance coverage.

“The cost [of branded GLP-1s] can sometimes be higher, or there may be a little bit more work and hoops to jump through in order to get them covered,” explains Stacia Woodcock, PharmD, Pharmacy Editor at GoodRx.

How do you find out if your insurance will cover a GLP-1?

A formulary is a list of medications that your insurance plan covers. It usually has different tiers, with each tier level containing a different cost level or copay. 

A higher tier of medication may involve additional steps for approval before it is covered. It may also have specific criteria for when the medication will be covered (such as if you have Type 2 diabetes or are considered obese). 

You can access your insurance formulary by looking at your plan online. You can also call your insurance company and talk to a representative. 

What should you ask your insurance company about GLP-1 coverage?

Ask your insurer if the branded GLP-1 medication is covered, as well as: 

• What tier is it in?

• What is the copay?

• Is prior authorization needed?

• Is step therapy needed?

Prior authorization means that your prescriber has to provide justification for why you need a particular medication before it’s approved. Insurance companies may also require step therapy, which means that they want you to try a lower-cost medication before they’ll cover the higher-cost option.

In order to understand the process of prior authorization or step therapy, you should consult your prescriber or your insurance company.

You may need to have clinical documentation that you have the health condition that a certain GLP-1 medication is approved to treat. “That usually requires a prescriber’s visit,” says Woodcock. “It may require some blood tests to show that you actually have these conditions.”

What can you do if your insurance denies coverage of a GLP-1?

If your insurer denies coverage for a GLP-1 medication, keep in mind that most insurers have an appeals process. If you want to file an appeal, make sure to ask your healthcare team to help you with the process.

“They usually have a dedicated billing associate that can really work hand in hand with you to get this covered,” says Woodcock.

If the appeal doesn’t work, you might also find out whether your insurer does cover a different GLP-1 medication. You may be able to switch to a different GLP-1 and get it covered.

If neither of those options is successful, you can investigate cost-savings opportunities. For example, you may be eligible to get your GLP-1 medication for free through a patient assistance program. If you’re paying cash, direct pharmacy options may offer your GLP-1 at a discounted price. With a free GoodRx coupon, you could pay as little as $499 per month for Ozempic and $499 for a 28-day supply of Wegovy. You can also get Wegovy delivered to your home for $499 through NovoCare Pharmacy.

“[These savings opportunities] can reduce your out-of-pocket costs to make these medications more affordable without insurance coverage,” adds Woodcock.