Key Findings
High Out-of-Pocket Burden for Patients Fighting Denials
Among patients currently taking a GLP-1 medication, we asked about their most recent out-of-pocket costs.
KFF Health Tracking Poll (2025) found 27% of insured GLP-1 patients pay the entire medication cost out of pocket.
GLP-1 Users Report Meaningful Clinical Improvements
Among the 63% of patients who reported prior GLP-1 use, we asked about clinical benefits experienced. Multiple responses were permitted.
Many Patients Lack Clear Explanations for Coverage Denials
Respondents were asked to identify the reason(s) their insurer provided for denying coverage. One option was "I'm not sure why I was denied."
Fewer than 1 in 10 denials are appealed—despite 80%+ success rates when patients do appeal (KFF, AMA).
A Large Share of Denied Patients Have Prediabetes
Respondents self-reported their diabetes status at intake. This finding is notable because prediabetes often does not meet insurer criteria for GLP-1 coverage, despite patients seeking preventive treatment.
70% of prediabetes cases progress to T2 diabetes (AAFP), which costs U.S. healthcare ~$380B annually (ADA).
Formulary Exclusion Is the Leading Barrier to GLP-1 Access
Respondents were asked to identify the reason(s) provided by their insurer for denying coverage. Multiple selections were permitted.
Formulary exclusion means the medication is not included on the insurer's drug list for the plan. In these cases, the drug is not covered regardless of clinical documentation.
GoodRx reports that 51% of commercially insured patients lost Zepbound coverage after CVS Caremark made it nonpreferred or excluded on its most common commercial formularies in July 2025. (Update: Since October 1, 2026, Zepbound is back on CVS Caremark’s commercial template formularies as an additional preferred option (plan sponsors can customize).)
Step Therapy Is Common Before GLP-1 Approval
Step therapy requires patients to try and fail on alternative medications before insurers will cover their preferred GLP-1. We asked respondents about prior medications tried.
National Context
Patient-reported findings align with multiple published national benchmarks:
Methodology
Data Source
Self-reported patient assessments collected through Find Honest Care's GLP-1 coverage assistance platform during Q3–Q4 2025.
Sample Size & Precision
With 1,000+ respondents, reported percentages carry an estimated ±3 percentage point margin of error at a 95% confidence level.
Study Limitations
- Self-selected patient population
- Self-reported data not independently verified
- Findings are not nationally representative
Update Cadence
This report is updated on a quarterly basis as new assessments are collected.
Sources Cited
- GoodRx. Live Updates: Tracking Insurance Coverage for GIP and GLP-1 Agonists Like Zepbound and Wegovy. November 2025.
- Kaiser Family Foundation. 2025 Employer Health Benefits Survey. October 2025.
- Liu et al. Coverage and Prior Authorization Policies for Semaglutide and Tirzepatide in Medicare Part D Plans. JAMA Network Open, August 2025.
- BenefitsPro. Over 97M Americans now lack commercial coverage for Zepbound. August 2025.
- American Academy of Family Physicians. Prediabetes Diagnosis: Helpful or Harmful? December 2021.
- American Diabetes Association. Annual Costs of Diabetes: $412.9 Billion. November 2023.
- Kaiser Family Foundation. Claims Denials and Appeals in ACA Marketplace Plans in 2023. January 2025.
- American Medical Association. Over 80% of Prior Auth Appeals Succeed. Why Aren't There More? October 2024.
This report is provided for informational and educational purposes only. Honest Care does not provide medical diagnosis, treatment, or clinical recommendations. Insurance coverage policies vary by plan and may change over time.
Disclaimer
The information on this page is for educational and informational purposes only and is not intended as medical advice. Honest Care does not provide medical diagnosis, treatment, or individualized recommendations. Always seek the advice of your physician or other qualified healthcare professional regarding any medical condition or treatment.
While this content has been reviewed for accuracy and balance, new evidence may emerge after publication. Drug availability, indications, and insurance coverage can change over time. Honest Care makes no warranties as to completeness or currentness of the information and is not responsible for decisions made based on this content.