• 42% of U.S. adults live with obesity (BMI ≥30)

  • 1 in 8 adults (12%) have used a GLP-1 drug; 6% are currently using one

  • Semaglutide prescriptions grew 442% nationally between 2021 and 2023

  • Covering GLP-1s for obesity can add $30–$70 PMPM to employer costs

  • U.S. annual GLP-1 spend could exceed $100 billion within 5 years without utilization management

  • About 40 manufacturers are developing GLP-1s, with 16 new obesity drugs expected between 2026–2029

  • 13 state Medicaid programs now cover GLP-1s for obesity

  • Only 18% of large employers cover GLP-1s primarily for weight loss

Prior Authorization (PA) Basics

  • Purpose: Prior Authorizations are utilized by health insurers to manage medication use, ensuring appropriate therapy, controlling costs, and verifying clinical necessity before coverage is approved.

  • Common Requirement: Both semaglutide and tirzepatide typically require prior authorization due to their high cost and specialized use.

  • Process: Providers submit documented clinical information supporting the prescription, including medical history, diagnostic criteria, and prior treatment response.

Impact on Employers and Manufacturers

  • PAs for GLP-1 therapies influence patient access and adherence.

  • Efficient PA processes help reduce delays in treatment initiation.

  • Evidence-based PA strategies optimize outcomes and contain overall healthcare costs.

FACTS: Employers Need to Know

FAQ’s:

Q1. Why is a prior authorization (PA) required?
PA is used to control costs and ensure appropriate use. As specialty drug spend grows, payers require more PA to align use with FDA-approved indications.

Q2. What does covering GLP-1s for obesity cost an employer?
Covering GLP-1s can add $30–$70 per member per month (PMPM) depending on uptake.

Q3. Why are so many GLP-1 claims initially denied? Most denials result from missing documentation or benefit exclusions. About 80% of appeals are overturned if the drug is FDA-approved and not excluded by plan design.

Q4. How can employers offer access without breaking their budget?
Employers can adopt tiered eligibility criteria, optimize rebates, and evaluate carve-out programs to balance access with affordability.

Q5. What role does Zeprx play with pharmaceutical manufacturers?
Zeprx consults with drug manufacturers on formulary strategy, providing payer insights on rebate structures, launch positioning, and how new therapies may be evaluated.

Q6. How many GLP-1 drugs are coming to market?
About 40 manufacturers are developing GLP-1s, with 16 new obesity drugs expected between 2026–2029.

Q7. How common is obesity in the U.S.?
Roughly 42% of U.S. adults — about 140 million people live with obesity (BMI ≥30).

Q8. What about compounded GLP-1s?
The FDA has stated that compounded versions of semaglutide and tirzepatide are not approved and should only be used when a drug shortage prevents access to the brand product. Despite this, many compounding pharmacies and telehealth platforms continue to provide GLP-1s to cash-pay customers.

Sources: ICER 2025 White Paper; KFF 2024; CDC/NCHS 2023; Zeprx managed care expertise