Zepbound, Wegovy: GLP-1 Coverage Challenges For Payers
Posted on September 11, 2025
Payers Have Limited Solutions To Manage GLP-1s For Obesity
Key Points
- GLP‑1 coverage for obesity remains limited, with only 39% of payers offering it.
- Wegovy and Zepbound dominate the obesity GLP‑1 market, each with unique clinical profiles and expanding indications that complicate benefit design.
- PBM programs vary widely and can sometimes lead to more operational and member experience challenges.
- Cash‑pay options and carve‑out strategies are emerging, but they add complexity and require careful evaluation.
- Payers need a structured framework to balance affordability, access, and member experience while aligning with clinical goals and budget constraints.
Patients, providers and payers continue to navigate the challenging landscape of GLP-1s. The pipeline is robust with formulations offering potential for improved dosage forms, dosing, and efficacy. As trend and spend continue to rise, PBMs are introducing a range of strategies and programs aimed at improving member access and driving potential cost savings. These efforts, however, leave plan sponsors facing tough decisions as they try to balance affordability, access, and member experience.
According to PSG’s 2025 Trends in Drug Benefit Design Report, a comprehensive survey of over 200 healthcare payers including health plans and employers, nearly all respondents cover GLP-1s for type 2 diabetes but only 39% provide coverage for obesity. In addition, 17% of plans are actively considering coverage while 5% who previously covered these drugs have since excluded them. When it comes to coverage for obesity, affordability and access remain top challenges for payers and patients.
Access
Currently in the U.S. market, Novo Nordisk’s Wegovy and Eli Lilly’s Zepbound dominate the market share of obesity GLP-1s. The competition is on between the products.
| Wegovy (Semaglutide) | Zepbound (tirzepatide) | |
|---|---|---|
| Manufacturer | Novo Nordisk product | Eli Lilly product |
| FDA Approval | FDA-approved June 2021 | FDA-approved November 2023 |
| Expanded Indications | – MACE risk reduction in adults with obesity or overweight – Adults with MASH | – Obstructive sleep apnea in adults with obesity |
| Average Weight Loss | 13.7% weight loss* | 20.2% weight loss* |
While both products experienced intermittent shortages in 2024, they seem to be resolved, allowing sufficient access to both drugs in the current market. Novo and Lilly continue to emphasize their support for coverage of both Wegovy and Zepbound to preserve patient and provider choice.
Expanded Indications
In addition to being indicated for patients with obesity or overweight, both drugs have gained expanded indications for other conditions in patients with obesity. Most recently, Wegovy gained an expanded indication for treatment of noncirrhotic metabolic dysfunction associated steatohepatitis (MASH) with moderate to advanced liver fibrosis in adults with or without obesity. Zepbound is also being studied for MASH, and both drugs continue to be examined for additional expanded indications. The impact that new expanded indications will have remains to be seen.
Affordability
Affordability remains the biggest challenge in providing coverage for GLP-1 medications used for obesity. Many payers have not found a sustainable way to offer coverage for members seeking these drugs. Among those who do offer coverage, some have had to tighten utilization management (UM) protocols, while others have removed coverage altogether. This has created significant challenges, and many payers are seeking solutions from their PBMs. However, the solutions offered by PBMs have varied widely and often do not fully address the key concerns of most payers: access, affordability, and a positive member experience.
There are notable differences in rebates and net costs between GLP-1 medications for diabetes and those for obesity. Typically, the net costs for diabetes GLP-1s are lower. This disparity has frustrated payers who cover obesity GLP-1s, leading them to seek savings or lower costs for all GLP-1 medications.
Both Novo and Lilly are providing “cash-pay” options for their obesity GLP-1s, Wegovy and Zepbound, through programs for individuals lacking insurance coverage. Wegovy is priced at $499 for all doses when obtained via NovoCare®, while Zepbound costs $349 for the starter dose and $499 for all other doses when purchased through LillyDirect®. These programs ensure that the medications are shipped directly to patients. Recently, Novo has also made Ozempic available through NovoCare®.
| Wegovy (Semaglutide) | Zepbound (tirzepatide) | |
|---|---|---|
| Monthly List Price | $1349 not net of rebates | $1086 not net of rebates |
| Monthly Patient Cash Price | $499 all doses | $349 starter dose, $499 other doses |
What Impact Do Limited PBM GLP-1 Management Solutions Have On Payers?
Payers are looking for the best solution(s) to ensure affordability, provide access, and offer a positive member experience. Instead, they are faced with limited solutions and a variety of challenges:
Access and Choice Constraints
- Narrow dispensing networks and limited pharmacy options require payers to enroll in a select network of only a few pharmacies for the dispensing of all GLP-1 medications.
- Formulary restrictions may favor one GLP-1 medication over others, even when their efficacy varies, despite market concerns about limiting access.
- Exception pathways may exist but are often narrow (e.g., prior failure criteria), adding administrative complexity and potential delays, which could incentivize individuals to seek alternative sources for excluded medications.
Complex and Unclear Affordability and Savings
- Programs like enhanced offerings for “high-touch” patient support increase complexity and can cloud sources of savings or lack of transparency to any additional costs.
- Rebate dynamics may limit flexibility. Tightening UM or adjusting benefit design (higher copays) might jeopardize rebates.
- Manufacturer cash pay offers (e.g., $349–$499 per month) allow for a low price; however, leveraging them typically requires carve-out strategies that many plans don’t have in place.
Member Disruption
- Forced product switches and limited dispensing sites can disrupt care and cause member dissatisfaction.
- Members currently using GLP-1 medications at the restricted dispensing sites may lose access unless their plan sponsor subscribes to the new program.
- Programs that don’t support optimal weight loss efficacy may undermine perceived value, even when framed as cost savings.
Clinical and Benefit Design Inflexibility
- Some offerings restrict UM levers (e.g., step edits, prior authorization criteria), implement automated processes that result in increased utilization, or limit copay changes due to rebate or contract risk.
- Some solutions may not prioritize optimal weight loss when limiting GLP-1 choice to one drug, impacting optimal outcomes.
- Higher costs for GLP-1 medications prescribed for obesity compared to those for diabetes could raise affordability pressure for plans covering obesity.
Some payers have agreed to PBM solutions they worry are not going to provide the best member experience, but did so because they felt they had no other options available. In certain instances, they opted for these solutions to avoid having to remove coverage for obesity medications.
Final Thoughts
Understanding all the nuances and details of the various program offerings can be very challenging for payers. Leveraging use of integrated data, industry insights, and market experience can be extremely helpful in navigating the current and future coverage of obesity GLP-1s. PSG is ready to help.
Please reach out and we can connect you to one of our clinical consultants who can help you develop the strategies that align best with your clinical goals, organizational values, and budget constraints.
