May 9, 2025

Ensuring Equitable Access

Our priority is to ensure that glucagon-like peptide-1 (GLP-1) medications are used safely and appropriately according to their current approved uses. Demand for these medications has increased significantly, often for uses that are not approved by the Food and Drug Administration (FDA). This off-label use has contributed to drug shortages, limiting access for members who rely on these medications to manage serious health conditions.

To ensure appropriate use and sustained access to GLP-1 receptor agonists, the following updates to the utilization management strategy, for all FDA-approved indications including Type 2 diabetes, chronic weight management and cardiovascular risk reduction, have been implemented. 

Aligning Use with Clinical Expertise

To ensure safe and clinically appropriate prescribing, all GLP-1 medications require prior authorization and will only be authorized for uses approved by the FDA. For type 2 diabetes treatment, GLP-1 medications are covered if the member meets plan-specific prior authorization criteria.

Beginning Sept. 1, 2025, prescriptions for GLP-1 agents used to treat type 2 diabetes must originate from an authorized provider whose practice scope includes the diagnosis, monitoring and management of diabetes. Coverage for other FDA approved uses (e.g., chronic weight management) varies by formulary and plan design.

Off-Label Use and Understanding Coverage Limitations for Expanded Indications 

Some GLP-1 medications now carry additional FDA-approved indications that include: 

• Zepbound^® (tirzepatide) for obstructive sleep apnea (OSA) in adults with obesity 
• Wegovy^® (semaglutide) for major adverse cardiovascular even (MACE) reduction in adults with overweight or obesity and established cardiovascular disease 

Despite these new indications, both remain classified under the broader category of anti-obesity agents. For members whose benefit plans exclude weight loss medications these agents are not covered, even when prescribed for OSA or cardiovascular risk reduction. 

This is because:

• Coverage determinations are based on drug classification, not specific indication.
• If a plan does not cover weight loss medications, it will not cover Zepbound or Wegovy regardless of whether the diagnosis is sleep apnea or cardiovascular disease. 
• These indications are still linked to obesity as the qualifying condition, and therefore subject to the same exclusion criteria. 

Note: This information applies exclusively to our commercial and Marketplace (Exchange or Affordable Care Act) plans. It does not apply to Medicare and Medicaid, as coverage for these programs is determined by state and federal regulations.

If you have questions, feel free to contact your Provider Relations Consultant for assistance.