---
type: source
title: "GLP-1 Managed-Access Operating Systems: How Payers Are Building Infrastructure Beyond Formulary"
author: "on/healthcare tech (strategy analysis)"
url: https://www.onhealthcare.tech/p/how-commercial-insurers-self-insured
date: 2026-01-01
domain: health
secondary_domains: []
format: analysis
status: processed
processed_by: vida
processed_date: 2026-04-28
priority: high
tags: [GLP-1, payer, infrastructure, managed-access, value-based-care, employer-benefits, utilization-management]
intake_tier: research-task
extraction_model: "anthropic/claude-sonnet-4.5"
---

## Content

Strategic analysis of how payers, PBMs, and employers are restructuring GLP-1 access as a managed-access operating system rather than a standard formulary decision.

**The core argument:**
Traditional yes/no formulary structure cannot accommodate GLP-1 economics:
- Eligible population: 36.2 million commercially insured adults
- Cost: $1,000-$1,200+/month recurring
- Multiple indications: obesity, T2D, cardiovascular risk (2024), MASH F2-F3 fibrosis (2025), sleep apnea (December 2024)
- The decision tree: which populations qualify, under what thresholds, through which channels, with what behavioral gates, at what subsidy levels, with what discontinuation rules

This requires an operating system, not a formulary.

**Payer infrastructure being built (2025-2026):**

Evernorth EncircleRx:
- Manages 9 million enrolled lives
- 15% cost cap or 3:1 savings guarantee
- ~$200 million saved since 2024
- $200 copay cap on Wegovy and Zepbound added 2025

Optum Rx Weight Engage:
- Pairs GLP-1 access with obesity specialist navigation, coaching, lifestyle programs

UHC Total Weight Support:
- Requires coaching engagement (Real Appeal Rx or WeightWatchers) as COVERAGE PREREQUISITE
- [Note: WeightWatchers bankruptcy creates a gap here — the mandated vendor went bankrupt]

**Manufacturer direct-to-employer channels (early 2026):**

Eli Lilly Employer Connect (March 5, 2026):
- $449/dose Zepbound direct to employers (vs. $1,000+ retail)
- 15+ program administrator partnerships: GoodRx, Teladoc, Calibrate, Form Health, Waltz
- Bypasses PBMs entirely

Novo Nordisk parallel DTE:
- Waltz Health and 9amHealth partnerships
- Launched January 1, 2026

**Indication expansion creating complexity:**
- Wegovy: cardiovascular risk reduction (2024)
- Wegovy: noncirrhotic MASH with F2-F3 fibrosis (2025)
- Zepbound: moderate-to-severe obstructive sleep apnea (December 2024)
Each indication requires distinct medical-necessity criteria and cost-offset narratives.

**The persistence problem (framing the infrastructure need):**
Meta-regression data:
- ~50% discontinuation within one year
- ~60% weight regain within 12 months of cessation
- 1-in-12 patients remain on therapy at three years (Prime Therapeutics, cited by Mercer)
These numbers make the ROI case for managed access infrastructure: without behavioral gates, drug-only GLP-1 coverage is cost without durable benefit.

**Infrastructure opportunities identified:**
- Utilization management infrastructure
- Outcomes-based contracting frameworks
- Indication-specific cardiometabolic programs
- Adherence, tapering, and discontinuation management systems
- Employer-side financing or subsidy products

**Coverage expansion from search data:**
- 43% of 5,000+ employee firms cover GLP-1s for weight loss (up from 28% in 2024)
- 34% now require behavioral participation as coverage condition (up from 10%)
- State mandates emerging: North Dakota first (January 2025), California/Connecticut/West Virginia introducing similar legislation
- CMS: Medicare Part D coverage beginning January 2027

## Agent Notes

**Why this matters:** The "managed-access operating system" framing is conceptually important. The previous KB description of GLP-1 economics treated the drug as a standalone product with an adherence problem. This analysis shows that payers are treating the drug + behavioral infrastructure as a SYSTEM — a complex managed product requiring ongoing operational management. This changes the nature of what business opportunities exist.

**What surprised me:** The manufacturer direct-to-employer channels (Lilly Employer Connect, Novo/Waltz/9amHealth) launched in early 2026. This is manufacturers BYPASSING PBMs to sell directly to employers. If successful, this represents a structural shift in who controls GLP-1 access architecture. The PBMs (Evernorth, Optum Rx) are building infrastructure to stay relevant; manufacturers are trying to go around them.

**What I expected but didn't find:** More detail on which employers are using which vendor. UHC requires Real Appeal Rx or WeightWatchers coaching — but WeightWatchers went bankrupt in May 2025 (three months before this analysis). Does UHC now require the post-bankruptcy "clinical-behavioral hybrid" WeightWatchers? This gap in the record is interesting.

**New structural insight — the infrastructure layer is separate from the coaching layer:**
The previous session identified "behavioral support" as the moat opportunity. This analysis reveals a more complex infrastructure stack:
1. **Access layer**: PBM formulary, prior auth, utilization management (Evernorth, Optum Rx)
2. **Behavioral coaching layer**: Omada, Noom, Calibrate, WeightWatchers — where atoms-to-bits moat applies
3. **Contracting layer**: Outcomes-based contracts, risk-sharing (Evernorth's cost cap)
4. **Manufacturer direct layer**: Lilly Employer Connect, Novo/Waltz — bypassing traditional channels

Each layer has different moat characteristics. The behavioral coaching layer is where atoms-to-bits applies. The access/contracting layer is where PBM scale applies. The manufacturer direct layer is where brand power applies.

**KB connections:**
- [[four competing payer-provider models are converging toward value-based care with vertical integration dominant today but aligned partnership potentially more durable]] — the managed-access OS is a new configuration that doesn't fit cleanly into the existing four-model framework
- [[value-based care transitions stall at the payment boundary because 60 percent of payments touch value metrics but only 14 percent bear full risk]] — behavioral gates are a new mechanism for risk alignment at the pharmacy benefit level

**Extraction hints:**
- CLAIM: "GLP-1 economics require managed-access operating systems beyond standard formulary — payers are building multi-layer access infrastructure covering eligibility, behavioral gates, indication-specific criteria, and discontinuation management" — confidence: likely
- CLAIM: "Manufacturer direct-to-employer channels (Lilly Employer Connect March 2026, Novo Nordisk January 2026) represent structural challenge to PBM intermediation in GLP-1 access" — confidence: experimental (too new to confirm durability)
- UPDATE: The "inflationary through 2035" GLP-1 claim is further complicated by manufacturer DTE channels at $449/dose vs. $1,000 retail — pricing compression may be faster than expected

**Context:** on/healthcare.tech is a B2B healthcare strategy newsletter (paywalled). This represents sophisticated market analysis from the payer/employer strategy perspective, not consumer-facing.

## Curator Notes
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: The "managed-access OS" framing is conceptually new — it positions GLP-1 payer infrastructure as a distinct platform opportunity from behavioral coaching, adding a layer to the claim landscape
EXTRACTION HINT: Extract the managed-access OS framing as a new claim; separately extract the manufacturer-DTE structural disruption as a second claim — these are two distinct insights from the same source
