A recent budget impact analysis projects substantial cost increases for commercial health plans following the addition of weight loss (WL) benefits and expanded indications for glucagon-like peptide-1 (GLP-1) receptor agonists. Using real-world claims data, the study—presented at AMCP 2025—evaluated financial implications for a hypothetical 1-million-member plan lacking WL coverage.

The analysis modeled 1-year costs under a future scenario where the plan adds coverage for WL medications—specifically semaglutide (Wegovy), liraglutide (Saxenda), and tirzepatide (Zepbound)—and includes new US Food and Drug Administration (FDA)-approved GLP-1 indications for major adverse cardiovascular events (MACE) prevention, obstructive sleep apnea (OSA), heart failure (HF), and diabetic nephropathy (DN). Utilization projections drew from claims data (July 2023 through June 2024), epidemiological sources, and benchmarks from plans with existing WL benefits.

Incremental per member per month (PMPM) costs for GLP-1 therapy were highest for diabetes mellitus (DM) management at $17.16, followed by $2.73 for WL management and $0.67 for other newly approved indications. Total plan incremental PMPM costs were slightly lower due to offsetting factors: $16.25 for DM, $2.45 for WL, and $0.61 for other uses.

The authors noted that, “While WL costs may not rise significantly due to strict criteria for prior authorization and limited eligible prescribers, DM-related costs are projected to increase substantially.”

The study attributes the projected DM-related cost increase to a combination of off-label use for WL, growing utilization of GLP-1s with DM indications, and a lower cost profile for DM-approved GLP-1s than those with WL indications. “The GLP-1 with DM indication utilization is increasing, potentially due to off-label usage for WL, anticipated off-label usage for expanded indications, a shortage of GLP-1 with WL indications, and the lower cost of GLP-1 with DM indications,” the authors stated.

Health plans considering WL benefit implementation and coverage of new GLP-1 indications face a complex cost landscape. Although WL coverage introduces a modest PMPM increase, the larger financial pressure may stem from increased utilization of DM-approved agents for off-label purposes, signaling a need for ongoing utilization management and cost monitoring.

Reference 
Vu H, Keast S, Qiu W, Hendricks J. Budget impact model for commercial health plans after the implementation of weight loss benefit and with expanded FDA approval indications for GLP-1 agonists. Presented at: AMCP 2025; March 31-April 3; Houston, TX.