Glucagon-like peptide-1 receptor agonists, more commonly referred to as GLP-1s, have undoubtedly garnered much fanfare the past five years. This class of medications is prescribed for many indications including diabetes, weight loss, and to reduce the risk of heart attack and stroke in adults with heart disease. The first GLP-1, Byetta (exenatide), was approved by the Food and Drug Administration (FDA) in 2005 to treat diabetes mellitus Type 2. It was not until 2014 that the first GLP-1 was approved for weight loss (Saxenda [liraglutide]). In the ten years since exenatide appeared, there have been multiple newer, more effective agents that have received approval and been brought to market. Due to their resounding success, GLP-1s are currently being studied for many additional indications, among them Alzheimer’s disease and Parkinson’s disease.
GLP-1s as a weight-loss agent
Originally designed to treat Type 2 diabetes, it was observed the GLP-1s also provided other benefits such as weight loss. According to current research, in combining these mediations with lifestyle modifications patients can typically expect to lose between 5 percent and 21 percent of their body weight depending on specific medications and individual factors. The GLP-1s that have been FDA-approved for weight loss as of March 2025 are Wegovy (semaglutide), Saxenda (liraglutide), and the GLP-1/GIP dual receptor agonist Zepbound (tirzepatide). The effectiveness and popularity of GLP-1s have caught the attention of both manufacturers and insurance companies alike.
Coverage challenges
The current out-of-pocket cost for GLP-1s is approximately $1000 per month. Since the prices are so high, insurance companies now require prior authorizations with tight restrictions to control which patients qualify for coverage. A prior authorization—often called a “prior auth” and abbreviated PA or PAT—is the process in which a health care provider must obtain approval from the insurance company before prescribing certain medications or providing medical services in order for them to be covered (paid for) by insurance. Over the past few years, the number of medications needing prior authorizations has exploded. According to the American Medical Association, on average practices need to complete 43 prior authorizations per provider per week. These prior authorizations take approximately 12 hours to complete, which is a significant administrative burden.
The main criteria that insurance companies review to determine eligibility for GLP-1 medications for weight loss is Body Mass Index (BMI). BMI is a quick screening measure to assess a person’s weight relative to their height in order to estimate excess weight for height. Excess weight can increase the risk of developing high blood pressure, high cholesterol, and other chronic conditions. Initially, insurance companies required a patient to have a BMI of 30 or greater to agree to pay for a GLP-1 medication. However, some insurers have changed their criteria and now require a patient to have a BMI of 32, while some others require a BMI of 35. Other restrictions have also been recently changed or added, including: a trial (and failure) of non-GLP-1 weight-loss medications like phentermine; concomitant conditions like uncontrolled hypertension (blood pressure greater than 140/90); or registration and participation in an additional weight-loss program. Insurance companies also monitor compliance to approved regimens and expect to see certain weight-loss results—generally requiring a patient to lose at least 5 to 10 percent of their initial weight—for reapproval of prior authorizations and ongoing coverage. Based on recent history, the expectation is that criteria will continue to change and become more restrictive. And unfortunately, despite hard work from providers’ offices, there is still a chance that prior authorizations will be denied.
Compounded GLP-1s and pharmaceutical coupons
There has been significant patient interest in GLP-1s, and drug manufacturers have had difficulty producing enough medication to meet the high demand. In response, in 2022 the FDA declared medication shortages of four of these agents (liraglutide, dulaglutide, semaglutide, and the GLP-1/GIP receptor agonist tirzepatide). A medication shortage declaration removes some of the federal law restrictions on independent pharmacies and other facilities producing compounded copycat drugs for the general public. These compounded GLP-1s are available without a prescription from a medical provider, removing access barriers—and leading to the current ubiquitous advertisements from companies offering these services.
While the supply of GLP-1 medications made by FDA-approved manufacturers has improved, there are still challenges to their availability at local pharmacies. Compounding pharmacies generally do not have shortage problems, as the active ingredients (e.g. semaglutide) are readily available. Additionally, GLP-1s sold by a compounding pharmacy are much less expensive than their brand name or generic counterparts. While these formulations will not be covered by insurance, patients can save hundreds of dollars by purchasing from a compounding pharmacy.
However, there are other important considerations to using compounded medications. Compounders do not undergo the strict FDA approval process required of other medications, meaning that the final compounded product is not FDA-approved. And while the compounding pharmacies do use the same FDA-approved active ingredients as traditional manufacturers, they do not need to use the same additives. Additives are ingredients that can help extend a medication’s shelf life, improve color or taste, or maintain consistency; they are added to help create a useable medication form. This means that compounded products are not evaluated for safety, effectiveness, or quality, and there have been concerns raised about drug contamination, the amount and version of active ingredient used, dosing errors, and counterfeit products. The FDA urges patients to be vigilant when purchasing drugs online and only purchase from state-licensed pharmacies. The FDA’s BeSafeRx campaign has resources to safely buy prescription medications online.
The availability of compounded medications can also change. When the FDA removes a medication from the drug shortage list, compounding pharmacies must stop making the product. According to a recent FDA decision, tirzepatide and semaglutide have been removed from the shortage list and compounding pharmacies must cease making these medications by mid-May 2025. Patients who have been independently buying compounded GLP-1s may have to obtain prescriptions from their medical teams and work with insurance companies. For patients without insurance coverage for GLP-1s, some drug manufacturers also provide financial relief that can substantially reduce the out-of-pocket expense for patients with valid prescriptions.
Final considerations
In their short history as weight-loss agents, GLP-1s have proven to be an effective tool. GLP-1 medications are a useful instrument in our arsenal, but lifestyle modifications are needed as well. While many patients have experienced weight loss and improved overall health with a GLP-1, each person can react differently to medications. As with all pharmaceuticals, we urge patients to consult with their clinical team or pharmacist before starting any medications.
This article was published as part of a series for Obesity for World Obesity Day, March 4, 2025. View the full Special Series for more articles and messages from the editors regarding language and content.
Special Series
About the authors
Robert Viercinski, PharmD, MBA, DPLA, is the Manager of Specialty Pharmacy Operations at the Cambridge Health Alliance, an Integrated Delivery Network in the greater Boston area in Massachusetts. As a pharmacist with almost 20 years of experience, one of his major responsibilities is overseeing the organization’s prior authorization department.
Danielle Snivey, CPhT, has more than 25 years of experience as a pharmacy technician. She currently works in the prior authorization department at the Cambridge Health Alliance, an Integrated Delivery Network in the greater Boston area in Massachusetts.
**Feature photo obtained with a standard license on Shutterstock.
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