GLP-1 drugs did not slowly seep into pharmacy budgets. They showed up fast, expensive, and highly visible; driven not by physician promotion, but by unprecedented consumer awareness and demand. For many health plans and managed care organizations, what started as a coverage discussion quickly escalated into urgent questions from finance teams, employers, regulators, and members. How did spend spike this quickly, and what are we doing about it?
Unlike many specialty therapies, GLP-1 utilization is coming through consumers who are actively seeking treatment informed by direct-to-consumer marketing, social media, and cultural momentum around weight loss and metabolic health. This dynamic echoes the rapid surge seen in the early 2010s when Hepatitis C therapies boosted cure rates dramatically, triggering significant and, in some cases, destabilizing financial impact for managed care plans as costs outpaced premiums and forced renegotiation with state partners.
At the same time, these drugs sit at the intersection of obesity, chronic disease, stigma, and access. Every utilization management decision is now under scrutiny. When rules feel unclear or inconsistently applied, the impact extends beyond financial performance to show up in appeals, grievances, public perception, and member trust.
Learn how defensible, non-discriminatory utilization management anchored in thoughtful PBM strategies can help control GLP-1 and specialty drug spend.
What “Survives Scrutiny” Really Means
When GLP-1 spend spikes, scrutiny follows. It comes from state regulators, CMS, employer groups, accrediting bodies, and sometimes the media. Plans are expected to show that coverage decisions are clinically grounded, consistently applied, and fair across populations. That expectation is only getting stronger as attention on pharmacy benefit managers increases.1
For health plans, surviving scrutiny means designing utilization management that can be clearly explained and defended. Non-discriminatory UM has a few core characteristics. Criteria are rooted in evidence. Rules apply the same way across populations. Exceptions are real, not theoretical. And plans can demonstrate that they monitor for unintended inequities in access.
This matters even more for GLP-1s because of scale. More than 100 million US adults could qualify for obesity medications, creating budget exposure unlike most other drug classes.2 That level of spend invites questions, and plans need answers that go beyond “this is our policy.”
Step Therapy as the First Lever
When pharmacy costs rise quickly, step therapy is often the first control considered. Step therapy can help direct treatment toward lower-cost options for members who may respond well to them. But if used poorly, it becomes a delay mechanism that drives dissatisfaction and appeals.
Analysis led by the Institute for Clinical and Economic Review (ICER) highlights that step therapy through non-GLP-1 obesity medications can be clinically reasonable for some members, particularly when weight loss goals are modest and patients are closely monitored.3 The key is structure and speed. Step therapy works best when it is clinically coherent and operationally efficient.
Effective step therapy for GLP-1s tends to share a few traits:
- The sequence of therapies reflects clinical evidence, not just price
- Required steps have clear timelines so members are not stuck waiting
- An off-ramp to GLP-1 therapy is defined when first-line options fail
These details matter because delays quickly become health equity issues. Members with fewer resources, less health literacy, or limited time are more likely to abandon therapy when processes are confusing or slow or if they feel like they’re receiving “second-class care.”3 Strong PBM strategies recognize that operational friction is not evenly distributed.
Exception Pathways That Actually Work
Exception pathways are where plans prove that utilization management is individualized, not rigid. They are also where many utilization management programs quietly break down.
For GLP-1s and other specialty drugs, exception pathways should not feel like a scavenger hunt. Plans benefit when exceptions are clearly identified, easy to submit, and reviewed consistently. Common exception scenarios include intolerance to required step therapies, contraindications, continuity of care for stable members, or documented failure despite adherence.
From a scrutiny standpoint, exception pathways do important work. They show regulators and employer groups that policies allow for the application of independent clinical judgment. They reduce unnecessary appeals. And they give member services teams a clear story to tell when members ask, “What happens if this does not work for me?”
ICER has noted that restrictive coverage approaches can unintentionally block access for patients who would benefit most, particularly when exceptions are difficult to obtain.3 Plans that invest in transparent exception design often see lower grievance volume and better member satisfaction, even when overall approval rates do not change dramatically.
Clinical Criteria Governance Keeps Policies Defensible
One of the most common issues plans face with GLP-1 utilization management is drift. Criteria are set, then labels change, new indications are approved, pricing shifts, or public pressure increases. Without governance, policies become inconsistent across lines of business or outdated in ways that invite criticism.
Strong governance must be intentional. Plans benefit from a group that includes clinical leadership, pharmacy, compliance, and operations, with a regular cadence to review and update criteria as part of the ongoing utilization program review. Decisions should be documented with clear rationale tied to evidence and benefit design goals.
This is particularly important for GLP-1s as indications expand beyond diabetes management into weight loss, cardiovascular risk, and other conditions. What initially felt like a narrow obesity policy can quickly become a broader specialty strategy. Governance keeps PBM strategies aligned as the clinical and financial context changes.
Member Communications Are Part of Utilization Management
Utilization management does not stop at policy documents. It shows up in coverage determination letters, portal messages, call center scripts, and appeal responses. For GLP-1s, tone matters.
Members often interpret coverage decisions as value judgments about obesity, even when policies are clinically justified. Language that feels moralizing or vague increases frustration. Members want to know why a step is required, what to do next, how long it will take, and what happens if it fails.
The increased attention on PBM practices has made communication riskier. Pharmacy Times notes that PBMs are under growing pressure to demonstrate transparency and fairness in how access decisions are made.¹ Plans that treat communication as part of their utilization management strategy are better positioned when questions arise.
As GLP-1 utilization grows, plans are also expected to monitor whether utilization management policies affect some populations differently than others.
Equity monitoring does not require perfect data. It requires consistency and follow-through. Plans often start by reviewing approval and denial rates, time to decision, exception outcomes, and appeal overturn rates across available demographic or geographic markers. Patterns often show up in delays rather than outright denials.
ICER has emphasized that affordability constraints, when combined with restrictive utilization management, can worsen existing disparities in access to obesity treatment.3 Monitoring allows plans to identify where friction is highest and adjust processes before inequities become entrenched. This is where PBM strategies move from policy to proof.
Resilient Approaches
Demand for GLP-1 medication remains strong, indications are expanding, and public attention on access and pricing is not fading. Health plans and managed care organizations do not need perfect answers, but they do need defensible ones.
The most resilient approaches combine structured step therapy, transparent exception pathways, active clinical criteria governance, clear member communications, and ongoing equity monitoring. This will create utilization management programs that control costs without creating unnecessary risk.
Need support translating policy into workflows that stand up to scrutiny and work for members? Clearlink helps health plans and managed care organizations design and operationalize clinically focused utilization management, pharmacy and medical policy governance, appeals and grievances support, and equity-aware operational models.
Contact us to learn how we can get your organization moving in the right direction.
Sources:
1. PBMs, Pricing, and Policy: The Fight for Fair Access to GLP-1s, Pharmacy Times
2. Adult Obesity Facts, US Centers for Disease Control and Prevention
3. Affordable Access to GLP-1 Obesity Medications: Strategies to Guide Market Action and Policy Solutions in the US, Journal of Comparative Effectiveness Research