Maria never expected to jog again. Two years ago, chronic knee pain and severe sleep apnea left her breathless after one flight of stairs. After we decided to begin using Zepbound, she lost 47 pounds. The knee-replacement consent was torn up, her CPAP sat unplugged, and her blood pressure rivaled her college-athlete days. Now relief is tinged with dread. Blue Cross Blue Shield of Massachusetts (BCBSMA) will stop covering every GLP-1 written for obesity on January 1, 2026, unless an employer pays extra for a rider. That date is only a few months away.
Maria’s story is not just a local problem. From North Carolina’s State Health Plan to CVS Caremark’s formularies, insurers and pharmacy-benefit managers (PBMs) are locking millions of patients out of drugs that not only reduce weight but also cut heart attack risk, tame sleep apnea, improve A1C, and reduce inflammatory markers.
A Spreading Patchwork of “No”
- CVS Caremark, the nation’s largest PBM, removed Zepbound from its standard formularies on July 1, 2025; members must switch drugs or pay list price. As a physician for hundreds of affected patients, I launched a Change.org petition that has already drawn over 16,000 signatures, urging Caremark to rethink their decision.
- Blue Cross Blue Shield of Michigan eliminated Wegovy, Zepbound, and Saxenda for fully insured large groups at renewals that began in January 2025 — thousands have already lost coverage.
- Independence Blue Cross in Philadelphia barred all weight-loss GLP-1s on its commercial plans on January 1, 2025.
- North Carolina’s State Health Plan ended coverage in April 2024 after trustees deemed costs “unsustainable.”
- West Virginia paused its 1,000-member pilot when spending hit $1.4 million a month.
- HealthTrust, the benefits manager for New Hampshire’s public-sector teachers and municipal workers, dropped GLP-1 coverage this spring, abruptly stripping thousands of educators and state employees of access — a move I challenged in a “Union Leader” op-ed.
- TRICARE will stop covering weight-loss GLP-1s for TRICARE for Life and “direct-care only” groups on August 31, 2025; Prime/Select members can still get them if clinical criteria and prior authorization are met.
- Harvard Pilgrim will drop coverage of GLP-1s for weight loss on January 1, 2026; large/self-insured employers may opt to keep coverage (often with conditions), but the base merged-market plans exclude it.
Add employer caps and BMI cutoffs, and millions of Americans now have zero GLP-1 coverage for obesity, with the rest becoming more fenced behind complex prior-authorization mazes.
Why These Medicines Matter
GLP-1s are not about vanity or just a number on the scale. Semaglutide (Wegovy) lowers heart attack, stroke, and cardiovascular death risk by 20% in high-risk adults. Tirzepatide (Zepbound) just became the first drug approved to treat moderate-to-severe obstructive sleep apnea, cutting nightly breathing interruptions by more than half. Trials show improvements in A1C, triglycerides, inflammatory markers, and joint pain. That translates into fewer stents, fewer knee replacements and more fulfilling lives. And because obesity is chronic and relapsing, patients often need ongoing therapy. So, when coverage disappears, unfortunately, so do the progress and health benefits that were achieved.
High Prices Are Real, Short-Term Thinking Is Worse
A monthly supply still lists around $1,200. Nobody disputes that’s too high. But the best actuarial evidence shows the bill is front-loaded. A new Aon study of 50 million covered lives found that after year one, medical spend growth for GLP-1 users fell to half that of peers, and hospitalizations for major cardiovascular events dropped 44% within two years. Even conservative cost-effectiveness work, and a study in JAMA predicts large lifetime health gains — just not at today’s list prices.
Manufacturers must accelerate price reductions to improve coverage, but PBMs and insurers share blame. When Caremark singles out one GLP-1 for exclusion, it is practicing medicine without a license — deciding that the drug I judge best for Maria is off limits. PBMs sit in the middle, collecting markups and secret rebates that drive prices up, then pointing to those same high prices as a reason to drop coverage.
Coverage Bans Are the Bluntest Tool
The Institute for Clinical and Economic Review maps risk-sharing contracts, negotiated rebates, and evidence-based eligibility that trim budgets without shutting patients out. Some self-insured employers already use them. PBMs and state plans, instead, chose to slam the door.
Imagine an insurer declaring insulin “too expensive” for a patient with diabetes. We would call that inhumane. Obesity is no less chronic, and GLP-1 therapy is no less disease-modifying. When plans refuse to pay for prevention, they still foot the bill for heart bypasses and disability pensions — only later, and at greater cost.
January 1st for Massachusetts, and the National Clock Is Ticking
Benefit designs for 2026 lock in during autumn negotiations. BCBSMA can still reverse course, just as Caremark can still restore Zepbound. If they do not, other carriers will follow. Congress is now weighing the Treat and Reduce Obesity Act, which would finally let Medicare cover anti-obesity medications. The Congressional Budget Office estimates that change could cost about $35 billion over nine years — a price tag that makes many lawmakers flinch. The numbers strengthen two imperatives: Costs must come down and Washington must give seniors the same access already granted for other chronic-disease medicines. Without both pieces, millions of older Americans will remain shut out of a life changing therapy.
Almost three out of four American adults live with obesity or are overweight. Many have tried diet and exercise for decades. GLP-1s finally give biology-level help. These medications are not designed to replace nutrition and activity but rather complement and enable a healthier lifestyle in the first place. Rationing by spreadsheet tells them their health is a luxury rather than a priority.
Manufacturers should cut prices to increase access while PBMs and insurers should abandon blanket bans and adopt outcome-based contracts. Patients deserve decisions driven by evidence and partnership with their clinicians, not by opaque rebate politics.
Come January 1st, Maria may find herself choosing between rent and the injection that keeps her joints intact and her sleep apnea at bay. Multiply that dilemma by millions and the stakes become a public health emergency. We can invest in preventing chronic disease on the front end or pay exponentially more for strokes, heart attacks, and joint replacements on the back end. We must solve the affordability question but also have empathy and not abandon patients while we wait.
Joseph Zucchi, PA-C, MPAS, is a board-certified physician associate specializing in obesity medicine and clinical supervisor at Transition Medical Weight Loss in Salem, New Hampshire.
Names were changed to protect the patient's identity.
Image by Alphavector / Shutterstock
