Plan coverage of GLP-1s for weight loss: Compliance considerations
As the demand for GLP-1s for weight loss surges, many employers are evaluating whether and how their group health plans should cover these expensive drugs. GLP-1s like Wegovy and Zepbound have gained significant attention due to their FDA approval for chronic weight management and their demonstrated effectiveness in reducing obesity-related health risks. However, their high costs and expanding clinical indications have prompted employers to evaluate group health plan coverage policies carefully, balancing cost management with employee health needs and compliance risks.
This recently published article from Mercer’s Law & Policy Group discusses various compliance considerations for employers contemplating a range of cost-containment measures, from utilization management to coverage exclusions. The article also addresses:
- Special considerations for employers contemplating changing plan coverage in the middle of a plan year
- Market forces and evolving clinical developments that may influence plan design
- Basic compliance obligations—such as plan documentation—to keep in mind when modifying an employer-sponsored health plan in response to skyrocketing GLP-1 costs.
Employers may need to engage in regular review of GLP-1 coverage designs as vendor solutions promising cost-containment proliferate and the clinical indications for GLP-1s continue to evolve. However, before implementing any plan design change related to GLP-1s for weight loss, employers are encouraged to test the cost-savings assumptions and impact to member experience, and as always, consult with legal counsel about compliance requirements surrounding any cost or coverage changes. As they say, the devil is in the details, and it’s no different here. The specific compliance considerations will depend in large part on the details of the plan design and any coverage restrictions.
