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Meeting the Challenges of a Changing GLP‑1 Landscape

Dec. 31, 2025

(Applies to All Groups, Individual & Family Markets1)

Background

GLP‑1s are a class of medications prescribed to treat Type 2 diabetes mellitus, as well as obesity and obesity-related conditions. Blue Cross and Blue Shield of Oklahoma covers GLP‑1s that are FDA-approved to treat Type 2 diabetes as a standard benefit. However, GLP‑1s that are FDA-approved for obesity and obesity-related conditions are not a standard benefit with Blue Cross and Blue Shield of Oklahoma.

Key Challenges

  • GLP‑1s are guideline-recommended as first-line treatment for members with Type 2 diabetes. The clinical benefits and popularity of GLP‑1s have led to increased utilization of these medications. BCBSOK continues to focus on ensuring coverage and appropriate usage of the medication for members.
  • The FDA has approved the class of GLP‑1s to treat diabetes, obesity or other obesity-related conditions. All these variants have caused member confusion about treatment and benefit coverage.
  • The FDA reports resolving GLP‑1 shortages. However, consumers may be experiencing challenges at some pharmacies with limited products in stock.

With increasing demand for GLP‑1s, BCBSOK continues to evaluate access and management of these medications especially considering the following:

Coverage and Benefit Design

GLP‑1s that are FDA-approved for the treatment of Type 2 diabetes are a standard benefit covered for all BCBSOK members with prescription drug benefits administered by Prime Therapeutics®2. Some GLP‑1s that treat diabetes include Mounjaro, Ozempic, Rybelsus and Trulicity.

Self-Funded Group Coverage

BCBSOK also provides flexible benefit options for self-funded groups regarding coverage of FDA-approved GLP‑1s for weight management/obesity, such as Saxenda, Wegovy and Zepbound. Some of these benefit options below also apply to GLP‑1s for Type 2 diabetes.

  • Non-Obesity Conditions: GLP‑1coverage available for FDA-approved, non-obesity indications, such as sleep apnea or reduction of major adverse cardiovascular events.
  • New to GLP‑1 therapy? Initial prescriptions of covered GLP‑1s can be limited to a 30-day supply. Once the member reaches a maintenance dose, they may be eligible for more than a 30-day supply based on their benefits.
  • 30-Day Supplies: Another option can limit all applicable prescription refills to a 30-day supply for covered GLP‑1s and/or anti-obesity drugs.

For more information about these options, reach out to your account representative at BCBSOK, or your General Agency.

The Path to Treatment

BCBSOK routinely reviews its clinical programs and monitors GLP‑1 trends to ensure their members have safe, appropriate and cost-effective health care. The strategies listed below facilitate treatment for Individual & Family Markets and Group members with prescription-drug benefits administered by Prime.

  • As of Jan. 1, 2025, BCBSOK aligned with updated clinical guidelines to designate GLP‑1s as a first-line therapy in the treatment of diabetes. This allows members access to therapy without creating unnecessary delays.
  • Prior Authorization criteria for GLP‑1s that are FDA approved to treat Type 2 diabetes currently requires members have a Type 2 diabetes diagnosis that is supported by any of the following lab results:
    • An A1c value of 6.5 or above
    • A fasting plasma glucose of 126 mg/dL or above
    • A 2-hour plasma glucose of 200 mg/dL or above during oral glucose tolerance test (OGTT)
    • A random-plasma glucose of 200 mg/dL or above along with symptoms of hyperglycemia
  • Automated Approval Process: Using medical claims data, BCBSOK streamlines the approval process with pharmacies for the GLP‑1 Prior Authorization program. Members with a documented medical diagnosis of Type 2 diabetes may not need their provider to submit a prior authorization request manually. Rather, BCBSOK uses integrated data to automatically approve the prescription at the pharmacy counter without delay.

Dispensing Limits Update

Beginning Oct. 1, 2025, IFM and Group members with Prime are limited to filling one GLP‑1 prescription at one strength every 28 days. For example, a member could fill an injectable GLP‑1 prescription but not add an oral GLP‑1 prescription within the 28-day window. This policy helps reduce medication waste and avoids duplicating therapy.

If a member's health care provider prescribes a different dose within the 28‑day window, or if the member cannot tolerate their current GLP‑1 product and needs to switch to a different drug, the member can undergo a clinical review.

Dispensing Pharmacy Considerations

Pharmacies may have unique approaches to what they have in-stock. Members should first check with their pharmacy to confirm the medication is on hand and consider the following:

  • Some pharmacies may limit dispensing options to a 30-day supply or may no longer carry the product.
  • Effective June 15, 2025, Express Scripts® Pharmacy transitioned home-delivery prescriptions for covered injectable GLP‑1 drugs to EnGuide Pharmacy. This transition affects members whose drug benefits are administered by Prime and are refilling their injectable GLP‑1 prescription at Express Scripts Pharmacy.

Fighting Fraud, Waste and Abuse

BCBSOK also collaborates with Prime and our Special Investigations Department to monitor and intervene on atypical pharmacy and prescriber utilization. We also continue educating providers regarding electronic PA submissions, appropriate use of GLP‑1s and PA criteria.

Medicare and Medicaid

Medicare and Medicaid members follow similar requirements for GLP‑1s prescribed for Type 2 diabetes. The Centers for Medicare & Medicaid Services continues to cover GLP‑1s for diabetes or other FDA-approved indications outside of obesity, but they have not updated their guidelines regarding GLP‑1 coverage for obesity.

What’s new?

The GLP‑1 landscape is constantly evolving. We continue monitoring market changes and medication utilization. For example, BCBSOK now offers a pathway to coverage of Wegovy for treating MASH, a specific type of liver disease. Members diagnosed with MASH with moderate to advanced liver scarring (fibrosis) have a pathway for coverage when they meet certain clinical criteria. This pathway began Nov. 15, 2025, for IFM members and all groups – including ASO groups that exclude coverage of Wegovy for weight management.

BCBSOK is committed to ensuring clinical relevance and member safety by evaluating clinical criteria frequently.

For more information, please contact your account representative or General Agency.

 

1 This article, or a similar version, is being shared with employer groups in our employer newsletter or news alert.

2 Prime Therapeutics, LLC is a separate company Blue Cross and Blue Shield of Oklahoma contracts with to provide pharmacy solutions. BCBSOK, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime Therapeutics.