By Jake Velie, CPT, Founder, Chairman & CEO, National Integrative Health

The GLP-1 market has already changed. The real question now is not whether these therapies will keep growing. They will. The question is whether plan sponsors have a real strategy for managing them.¹ ²

Too much of the conversation is still framed the wrong way. It gets reduced to a yes or no coverage debate, cover it or exclude it, as if that alone settles the issue. It does not.² ³

Coverage alone is not a strategy. Exclusion alone is not a strategy either.

A plan sponsor can decide to cover GLP-1s and still lose control if there are no clear clinical criteria, no channel discipline, no oversight on duration of therapy, and no process for managing net cost. A plan can also choose to exclude them and still end up with pressure from members, employers, appeals, and market demand that does not go away.¹ ²

That is where the market is now. GLP-1s have moved past being a niche benefit question. They are reshaping employer conversations around pharmacy trend, specialty management, clinical governance, and fiduciary oversight.¹ ²

This split is already showing up in the market. PSG reported that nearly all plans now cover GLP-1s for diabetes, but only 40% offer them for obesity, and 49% of plans that do not cover obesity GLP-1s say they would not do so at any price. That tells you this is no longer a fringe benefits question. It is an active plan-design and cost-governance decision.³

That means the next step for plan sponsors has to be execution.

The first piece is clinical criteria. If a plan is going to cover these therapies, it needs a disciplined framework around who qualifies, under what conditions, with what documentation, and with what expectations for continued therapy. That includes diagnosis standards, prior therapy requirements where appropriate, prescribing oversight, and ongoing review. Without that structure, utilization expands faster than governance.² ³

The second piece is channel management.

Not every high-cost therapy should move through the same pathway without scrutiny. Plan sponsors need to know where a GLP-1 claim is being filled, what support programs may exist, what manufacturer assistance or patient advocacy pathways are available, and whether anyone is actively managing the lowest legitimate net-cost route. Too often, plans look at the claim only after the spend is already on the books.¹

That is reactive. It is not strategy.

We are also seeing what stronger GLP-1 discipline can look like in real plan modeling. In a de-identified jumbo-group analysis built on a U.S.-sourced formulary, NIH modeled a fixed all-in GLP-1 rate of $521 per utilizing member per month, 36% below the incumbent carrier’s standard estimate and 57% below its risk-managed estimate. That translated to projected annual savings of $11.5 million to $25.8 million, depending on member take-up.⁴ ⁵

Just as important, tighter guardrails did not raise the unit cost in that modeling. BMI thresholds, prior authorization, step therapy, and lifestyle-program requirements could be layered on without changing the price per fill. Under the incumbent’s rebate-based model, tighter eligibility raised the unit cost by 50%.⁴ ⁵

The third piece is net-cost discipline. This is where a lot of employers still stop too early. They may get more visibility into pricing, but visibility by itself does not solve the problem. Seeing spend is not the same as controlling spend. A report can tell you what happened. It cannot prove the plan used the best available pathway.¹ ²

That matters because GLP-1 demand is not slowing down. As more employers face pressure from utilization, workforce interest, and broader market normalization, the plans that do well will not be the ones with the loudest position. They will be the ones with the clearest process.¹ ³

That process should answer a few simple questions.

1. Who qualifies for therapy?

2. What clinical criteria must be met?

3. What channel should be used?

4. What cost-support options have been evaluated?

5. Who is accountable for the net result to the plan?

If a plan sponsor cannot answer those five questions clearly, it does not have a GLP-1 strategy yet.

This is also where employers need to be careful about confusing vendor activity with accountability. PBMs, TPAs, brokers, consultants, and clinical vendors may all play a role. But someone has to own the full picture. Someone has to be responsible for making sure access, clinical integrity, and financial stewardship are working together.

That is the gap I see in this market.

The conversation is finally catching up to the size of the issue. That is a good thing. But the next move cannot be more debate without operational discipline. Plans do not need another round of abstract opinions on GLP-1s. They need criteria. They need process. They need channel control. They need net-cost management.¹ ² ³

In short, they need a strategy.

Footnotes

1. Managed Healthcare Executive. “Growth of GLP-1 Therapies Has Reshaped the Market.” PBMI 2026, as summarized in AHIP Solutions SmartBrief, Sep. 15, 2026: GLP-1 therapies accounted for almost half of prescription drug sales growth, the diabetes market reached $98 billion, and weight loss treatments grew 75% year over year to $55 billion.

2. PLANSPONSOR. “Navigating the Current Landscape of GLP-1 Coverage.” Sep. 11, 2026. PLANSPONSOR NewsDash summary noting that attorneys from McDermott Will & Schulte reviewed the costs, benefits, and risks employers should evaluate when deciding how their benefits address GLP-1 medications.

3. PSG 2026 Trends in Drug Benefit Design Report webinar notes shared internally on Jun. 25, 2026: nearly all plans now cover GLP-1s for diabetes, 40% offer GLP-1s for obesity, and 49% of plans that do not cover obesity GLP-1s would not do so at any price.

4. National Integrative Health, de-identified GLP-1 coverage cost analysis for a jumbo labor health and welfare fund, Aug. 2026: modeled fixed all-in GLP-1 pricing at $521 per utilizing member per month, compared with incumbent estimates of $800 standard and $1,200 risk-managed.

5. National Integrative Health. GLP-1 Program Case Study, de-identified illustrative summary, 2026: projected annual savings of $11.5 million to $25.8 million depending on member take-up, with the same pricing holding under added utilization-management guardrails.