---
type: source
title: "Medicare Beneficiaries Face Near-Universal Prior Authorization for GLP-1 Drugs"
author: "Medical Economics"
url: https://www.medicaleconomics.com/view/medicare-beneficiaries-face-higher-costs-near-universal-prior-authorization-for-glp-1-drugs
date: 2025-03-01
domain: health
secondary_domains: []
format: article
status: unprocessed
priority: medium
tags: [glp-1, prior-authorization, medicare-advantage, formulary, access-barriers]
---

## Content

Analysis of GLP-1 coverage and prior authorization requirements under Medicare Advantage plans.

**Prior authorization escalation:**
- PA requirements surged from 2.8-5% of GLP-1 prescriptions (2020-2023) to nearly 100% by 2025
- Both BCBS and UnitedHealthcare require PA for GLP-1 coverage under MA
- PA ensures only T2D-diagnosed patients can access (pre-obesity coverage)

**Coverage rates by drug (2025 MA formularies):**
- Injectable semaglutide (Ozempic): 98.0% of MA plans cover
- Tirzepatide (Mounjaro): 96.2%
- Oral semaglutide: 84.8%
- Dulaglutide: 87.5%

**Current exclusion:**
- GLP-1s for weight loss/obesity remain excluded under Medicare Part D (until BALANCE model / demonstration)
- Only covered for T2D, CVD risk reduction, or obstructive sleep apnea (FDA-approved uses)
- Only 13 state Medicaid programs covered GLP-1s for obesity as of January 2026

## Agent Notes
**Why this matters:** Near-universal PA for GLP-1s under MA is a signal of how capitated plans manage high-cost drugs. MA plans bearing full risk have strong incentives to RESTRICT access (short-term cost avoidance) even when long-term data suggests coverage would save money. This is a live example of the VBC misalignment the March 10 research identified — MA is value-based in form but short-term cost management in practice.
**What surprised me:** The PA escalation from <5% to ~100% in just 2 years is extreme. This is MA plans actively resisting GLP-1 adoption, not embracing it — which challenges the thesis that capitated plans would rationally cover prevention.
**What I expected but didn't find:** No data on how PA affects adherence/persistence. If PA creates delays and access friction, it may worsen the already-terrible adherence rates. No analysis of whether MA plans with higher GLP-1 coverage have better downstream outcomes.
**KB connections:** Directly relevant to the March 10 finding that MA is VBC in form but misaligned in practice. Also connects to [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]].
**Extraction hints:** The PA escalation could support a claim about short-term cost management overriding long-term prevention incentives even under capitation.
**Context:** The near-universal PA will change significantly when the BALANCE model launches and Medicare GLP-1 demonstration begins in July 2026. This archive captures the pre-demonstration baseline.

## Curator Notes (structured handoff for extractor)
PRIMARY CONNECTION: [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]]
WHY ARCHIVED: Near-universal PA for GLP-1s under MA demonstrates that capitation alone doesn't align incentives for prevention — MA plans still manage to short-term cost metrics
EXTRACTION HINT: Focus on the tension between theoretical capitation incentives (cover prevention → save money) and actual MA behavior (restrict access → minimize short-term spend)
