After careful evaluation, COPS Trust has decided to exclude coverage of GLP-1 receptor agonist medications — such as Ozempic, Wegovy, Zepbound and Saxenda — when prescribed solely for weight loss.
We understand that changes to your health coverage can be deeply personal, and we want to be transparent about why groups like yours are making these decisions:
- Extraordinary cost: These categories of drugs – particularly GLP-1 medications used for weight loss and certain rare disease treatments – have seen dramatic price increases. In many cases, the cost of a single prescription can exceed tens of thousands of dollars annually.
- Limited clinical effectiveness: While some of these drugs show promise, many have not demonstrated consistent long-term efficacy across broader populations. Some patients experience significant weight loss, while others see minimal or no benefit. This variability could be due to differences in patient characteristics, lifestyle interventions, and medication adherence.
- Discontinuation rates: Research by the Blue Cross and Blue Shield Association found that more than 30% of patients dropped out of treatment after the first four weeks and 58% of patients taking the medications for weight loss discontinued use before seeing a clinical benefit.
- Sustainability of your health plan: Covering these high-cost medications for a small number of individuals puts significant strain on premiums for all employees. The goal is to maintain a high-quality, affordable health plan that serves the greatest number of people effectively.
This decision ensures that GLP-1 medications remain available for members with Type 2 Diabetes, where they are proven to be medically necessary and life-sustaining.
Click here to learn more about the new GLP-1 requirements.
Prior Authorization Now Required for Orphan and Ultra Orphan Drugs
In addition, prior authorization will now be required for specialty medications classified as orphan and ultra orphan drugs.
Orphan drugs are used to treat conditions that affect fewer than 200,000 people in the U.S. Ultra-orphan drugs treat even rarer diseases, often affecting fewer than 10,000 people.
Prior authorization will require a review of these medications before your plan will cover them. This confirms you’ve tried the preferred alternatives and the drug is being prescribed appropriately.
In some cases, orphan drugs and ultra orphan drugs may not be suitable due to:
- Extremely High Cost: Orphan drugs often cost hundreds of thousands of dollars per patient annually. Ultra orphan drugs can exceed $1 million per year.
- Questionable Cost-Effectiveness: Many orphan drugs offer modest clinical benefit relative to their cost. Health technology assessments often rate them as low-value interventions when measured by cost per quality-adjusted life year.
- Limited Clinical Evidence: Due to small patient populations, clinical trials are often underpowered or lack long-term data. This creates uncertainty around efficacy, safety, and real-world outcomes.
- Regulatory Flexibility Doesn’t Guarantee Quality: Orphan drugs often receive accelerated approval or benefit from relaxed regulatory standards. While this speeds access, it can mean less rigorous testing compared to mainstream drugs.
If your provider does not obtain prior authorization when required, the medication may not be covered. Most approvals last for one year, after which your provider must reapply.
What’s next?
If you have questions about how these changes may affect you, please contact your HR team or benefits administrator
Thank you for your understanding.