Ozempic, Wegovy, Zepbound — the most requested drugs in America, at four figures a month, forever. Whatever posture your plan takes, take it with the math in front of you. Sixty seconds.
Strongest recruiting and retention signal in benefits right now. Real clinical upside for the right patients. No fights, no gray areas.
You just added the number above to your base — permanently, compounding at every renewal. Utilization rarely goes down; refill persistence and dependents push it up.
Prior auth with BMI/comorbidity criteria, required lifestyle-program enrollment, step therapy, and quantity limits typically cut spend 30–50% versus open coverage while keeping the benefit real.
Guardrails are only as good as the PBM enforcing them — and some PBMs profit when utilization rises. Expect appeals, employee friction, and the need to actually audit the criteria.
Diabetes indications stay covered (they almost always must); weight-loss use doesn't hit the plan. On paper, the impact above goes near zero.
Off-label workarounds and diagnosis drift leak spend back in quietly. Employees notice the exclusion — it reads as the plan saying no to the one drug they asked about. And you'll revisit this decision every single renewal.
Estimates are illustrative — actual impact depends on your PBM contract (rebate pass-through changes the per-user number by hundreds a month), your demographics, and your guardrail design. None of this is medical or legal advice; coverage rules for diabetes indications and state mandates vary.