As glucagon-like peptide-1 (GLP-1) drugs continue to gain popularity, employees may be wondering whether the medication is covered under their health plan when comparing options during open enrollment. This is likely one of the most common questions employees will ask this year.
Coverage for these medications is not uniform. It can vary by the condition being treated, the employer’s group health plan and even the individual drug within the GLP-1 class. Understanding how to look up coverage, rather than assuming it, can help employees avoid unexpected costs and make more informed choices during enrollment.
This article explores GLP-1 coverage, explains how to read a formulary and outlines steps to check coverage during open enrollment.
Why Coverage Varies
Insurers generally evaluate GLP-1 coverage differently depending on the reason a medication is prescribed. In particular, coverage is more common when a GLP-1 is prescribed for a use approved by the U.S. Food and Drug Administration (FDA).
Coverage tends to be relatively standard for a qualifying diagnosis of Type 2 diabetes, while coverage for weight management, now an FDA-approved use for GLP-1s in individuals with a body mass index of 30 or higher, or 27 or higher with an additional weight-related condition, varies more by employer and often comes with additional requirements. Because GLP-1s are relatively unique among drug classes, some employers also establish separate agreements directly with manufacturers, such as Lilly Direct, that operate outside of standard plan coverage.
Coverage can also differ among individual drugs within the same medication class. Two medications used for similar purposes may be treated differently within the same formulary, with one designated as preferred and the other excluded or placed on a higher-cost tier. For example, a plan may list one medication, such as Wegovy (semaglutide), as a preferred drug while placing another, such as Zepbound (tirzepatide), on a higher-cost tier.
Furthermore, coverage options continue to evolve. Because formularies can change during the plan year as pharmacy benefit managers renegotiate pricing or update preferred drug lists, coverage that applies today may not reflect what will be available under a plan selected during open enrollment.
How to Read a Plan’s Formulary
A formulary is the list of prescription drugs a health plan covers, sometimes referred to as a preferred drug list. Formularies are developed by a committee that typically includes pharmacists and physicians, and they are updated periodically as new drugs become available or as pricing negotiations change.
When reviewing a formulary for GLP-1 coverage, individuals should look for the following information:
- The medication—Check if the specific medication appears on the list at all, since an absent drug is generally considered nonformulary and may not be covered.
- Covered conditions—Examine the condition or diagnosis for which the medication is approved on that plan. For example, a GLP-1 may be covered for diabetes but excluded for weight management.
- Formulary tier—Identify the drug’s cost tier, as this affects how much is paid out of pocket relative to other covered medications. Plans may split prescription drugs into three-, four- or even five-tier groupings.
- Other requirements—Review any notations indicating additional requirements, such as wellness program participation, prior authorization or step therapy, attached to that specific drug.
Formularies are usually accessible through a plan’s member portal or benefits guide, and many insurers also allow employees to search for a medication by name before enrolling. Employees who are unable to locate this information online can also contact their plan administrator or HR representative directly for guidance.
How to Check for GLP-1 Coverage
During the open enrollment process, employees can take the following steps to check if their GLP-1 drug is covered:
- Locate the formulary or drug list for each plan option being considered and search for the specific GLP-1 medication in question.
- Note the condition under which the medication is covered, since coverage tied to diabetes or cardiovascular risk reduction is generally more consistent than coverage for weight management alone.
- Check whether prior authorization, step therapy or quantity limits apply to that medication under the plan.
- Contact the plan’s member services line, using the phone number typically listed on enrollment materials, to confirm current coverage details and ask about any documentation that may be required.
- Ask a prescriber’s office whether it can run a benefits check on a proposed medication, since many practices have tools to verify coverage before a plan year begins.
What to Do If a Medication Isn’t Covered
If a GLP-1 medication does not appear to be covered by a plan under consideration, employees still have options. A prescriber can request a formulary exception on the employee’s behalf, often supported by a letter of medical necessity explaining why the medication is appropriate. If an exception is denied, most plans allow for an appeal, and reviewing the denial notice for the stated reason is generally the first step. Employees may also want to ask their prescriber whether a different, better-covered medication in the same drug class could meet their treatment needs.
A growing number of manufacturers and telehealth providers also offer self-pay purchasing options for GLP-1 medications outside of insurance, which may be worth exploring for employees without coverage. Employees paying out of pocket for a prescribed GLP-1 can generally use a health savings account or health care flexible spending account to pay with pretax dollars, which may factor into how much they choose to contribute during enrollment.
GLP-1 coverage can shift from one plan year to the next, so employees are encouraged to review formulary details during every open enrollment period rather than relying on coverage confirmed in a previous year.
Contact your HR representative if you have any questions about health plans and prescription drug coverage.
This Know Your Benefits article is to be used for informational purposes only and is not intended to replace the advice of an insurance professional. © 2026 Zywave, Inc. All rights reserved.
