Policy in flux: The outgoing administration had proposed that the Centers for Medicare and Medicaid Services (CMS) be required to cover GLP-1s for treating obesity. While this may change with the new administration, the proposed implementation could significantly impact the commercial market, which often follows CMS’ lead.
Expanding scope: The U.S. Food and Drug Administration (FDA) recently approved Ozempic for reducing the risk of worsening kidney disease, kidney failure (end-stage kidney disease), and death due to cardiovascular disease in adults with Type 2 diabetes and chronic kidney disease. Additionally, Eli Lilly’s Zepbound was approved for treating moderate to severe obstructive sleep apnea in adults with obesity. Manufacturers are also pursuing expanded indications for other conditions including and non-alcoholic steatohepatitis/metabolic-associated steatohepatitis (NASH/MASH), which are in advanced trials and the FDA submission process. If approved, these expanded indications could increase treatment utilization and provide manufacturers broader access to the obesity market since many of them are often linked to comorbidities of diabetes and obesity. In many cases, this would circumvent a payer’s plan design restricting coverage for weight loss and increasing plan costs.
Robust pipeline, alternative sourcing: New entrants, including some pill-based GLP-1s, could lower prices, but increased utilization may outweigh cost reductions. Meanwhile, compounding of these drugs, driven by early supply shortages, continues despite litigation by pharmaceutical manufacturers. Compounded GLP-1 alternatives could offer lower-cost alternatives but could increase demand and utilization.
Emerging risks: Potential long-term impacts and risks of GLP-1s remain uncertain. Some newly apparent adverse side effects offer a cautionary note.

The remainder of 2025 will be pivotal in determining how these medications are integrated into health care systems, potentially setting new standards for managing obesity and its related conditions. As the conversation evolves, it will be crucial to implement thoughtful plan design and utilization management criteria to ensure clinical appropriateness in conjunction with dietary and lifestyle changes to balance access and plan costs. By doing this, we can safeguard access for patients who can truly benefit from these treatments without imposing an unsustainable financial burden for plan sponsors.

Instant Insights /

Could GLP-1s cause pharmacy plan bottom lines to balloon in 2025?

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