GLP-1s

IMPORTANT INFORMATION ABOUT HOW YOUR HEALTH PLAN WORKS

Weight Management Options and How it Works

The SEHP offers a variety of options for Weight Management Programs. One option available is the Weight Management Program through the HealthQuest program by Marathon Health. This program consists of an 8-week course that goes over different methods to assist with losing weight and keeping it off. The course offers a supportive, judgement free environment with a focus on understanding the thought process that goes into losing weight. HealthQuest also offers individual sessions with health coaches to help members focus on their health goals.  Health coaches help support members’ weight loss goals while holding them accountable. Interactive programs with health care providers may include services  as well as pharmaceutical options to assist members in their efforts. These pharmaceutical options include Anti-Obesity medicines (AOMs).

Anti-Obesity Medications (AOM) and What to Know About Them

There are several different types of Anti-Obesity Medications the consumer can utilize after consulting with their health care provider. There are tablet and injectable forms available.  While many have great success with these medications, there can be side effects each user should be aware of before starting these medications. Each member  should consult with their health care provider about the best Weight Management Option for them. These types of medications require Prior Authorization through the SEHP’s Pharmacy Benefit Manager (PBM)   Caremark to determine eligibility for coverage under the SEHP benefits.  

Why Are They So Popular?

GLP-1s have shown significant success in helping people with the following:

• Manage blood sugar levels

• Lose a meaningful amount of weight

• Reduce the risk of certain heart and metabolic conditions

Here is a summary of the GLP-1s and how the process works under the SEHP benefits, and which ones are under the Preferred level of benefits for members.

GLP-1 Summary

The Financial Impact on the State Employee Health Plan

While Anti-Obesity Medications can be an effective treatment for weight management, they also come with a high price tag for both the health plan and members. Because of increasing demand for these medications, the cost to the State Employee Health Plan (SEHP) to provide this coverage has increased significantly in the last year. These cost increases have impacted both the SEHP and the member costs. Many employer health plans across the country are feeling the significant impact of these drugs and are struggling to continue covering them due to the rising costs and popularity. 

Unlike many other weight loss options, the cost is an ongoing expense, so the financial impacts to the Plan are long term. Many state employee health plans have made the decision to eliminate coverage entirely for these drugs. Other states have looked for ways to provide coverage but added some additional guidelines around their usage. The SEHP is in this category with the addition of some new requirements starting January 1st, 2026

Coverage Thru the Health Plan Starting January 1st

To help keep health care affordable and sustainable, coverage for GLP-1 medications for weight management will be limited to people who meet specific clinical criteria.
All Anti-Obesity Medications require prior authorization by Caremark. Caremark has established prior authorization criteria for each medical condition approved for treatment. All prescriptions for weight management require: 

• Patients must have a Body Mass Index (BMI) of 35 or higher to qualify for coverage of GLP-1s for weight management. This criterion applies to all GLP-1 prescriptions for weight management issued or renewed after Jan. 1, 2026. 

• The GLP-1 drug prescribed must be covered on the SEHP’s Preferred Drug List. Wegovy® is currently the Preferred GLP-1 for weight management. Zepbound® is a Non Preferred drug unless the member has previously tried and failed using a Preferred product or is unable to use it for medical reasons. In this situation the members’ provider can submit medical documentation for review requesting an exception from Caremark after it’s reviewed for  approval.  

Prior authorization is required for new users and coverage will need to be re-approved periodically with documentation supporting the ongoing use and effectiveness in reducing weight.

Questions? SEHP Is Here to Help

• Contact your HR representative

• Visit the Caremark for plan details

• Check out the HealthQuest Health and Wellness program to support your wellness journey, especially Weight Loss Health Coaching availability

• Contact SEHP