{
  "meta": {
    "name": "U.S. GLP-1 Formulary and Coverage Change Tracker",
    "version": "1.0",
    "datePublished": "2026-07-31",
    "dateModified": "2026-07-31",
    "temporalCoverage": "2025-01-01/2026-10-01",
    "totalEvents": 16,
    "creator": "Weight Loss Provider Guide Research Team",
    "url": "https://weightlossproviderguide.com/research/glp-1-formulary-changes",
    "license": "https://creativecommons.org/licenses/by/4.0/",
    "description": "Event-level dataset of publicly documented U.S. GLP-1 formulary and related coverage changes, 2025–2026. Each record represents a single plan- or program-level formulary or coverage action."
  },
  "fields": [
    "event_id", "effective_date", "organization", "market_segment", "plan_scope",
    "drug_or_class", "indication", "change_type", "access_direction",
    "pa_transition", "source_title", "source_url", "last_verified", "notes"
  ],
  "events": [
    {
      "event_id": "F01",
      "effective_date": "2025-01-01",
      "organization": "Blue Cross Blue Shield of Michigan / Blue Care Network (fully insured employer clients)",
      "market_segment": "Commercial — carrier",
      "plan_scope": "Fully insured employer group plans",
      "drug_or_class": "GLP-1 drugs for weight loss",
      "indication": "Weight management",
      "change_type": "Indication exclusion — fully insured plans",
      "access_direction": "Narrowed",
      "pa_transition": "Existing authorizations ended; self-funded employer plans not affected",
      "source_title": "University of Michigan HR prescription plan update",
      "source_url": "https://hr.umich.edu/benefits-wellness/health-well-being/prescription-drug-plan/news-updates",
      "last_verified": "2026-07-31",
      "notes": "U-M is self-funded and kept its own coverage; the carrier decision did not control U-M's plan."
    },
    {
      "event_id": "F02",
      "effective_date": "2025-01-01",
      "organization": "University of Michigan Prescription Drug Plan",
      "market_segment": "Employer — university",
      "plan_scope": "U-M faculty and staff",
      "drug_or_class": "Injectable weight-loss GLP-1s (Wegovy / Zepbound / Saxenda)",
      "indication": "Weight management",
      "change_type": "Program requirement added alongside existing 24-fill lifetime limit",
      "access_direction": "Narrowed",
      "pa_transition": "Continuing members must enroll in concurrent weight-management program; new A1c and risk-factor documentation required",
      "source_title": "U-M Prescription Drug Plan News and Updates",
      "source_url": "https://hr.umich.edu/benefits-wellness/health-well-being/prescription-drug-plan/news-updates",
      "last_verified": "2026-07-31",
      "notes": "The 24-fill lifetime limit was introduced May 1, 2024; the concurrent program requirement was the Jan 1, 2025 change."
    },
    {
      "event_id": "F03",
      "effective_date": "2025-01-01",
      "organization": "NY44 Health Benefits Plan Trust",
      "market_segment": "Employer — benefit trust",
      "plan_scope": "NY44 active member plans",
      "drug_or_class": "GLP-1 drugs prescribed solely for weight loss",
      "indication": "Weight management",
      "change_type": "Exclusion — sole weight-management indication",
      "access_direction": "Narrowed",
      "pa_transition": "Existing users became responsible for full cost; payments outside the plan do not apply to deductible or out-of-pocket maximum",
      "source_title": "NY44 Website Communication About GLP-1 Drugs",
      "source_url": "https://www.ny44.e1b.org/wp-content/uploads/2024/11/NY44_GLP-1DrugsCommunication.pdf",
      "last_verified": "2026-07-31",
      "notes": "Brook+ diabetes-prevention program remained available to eligible members."
    },
    {
      "event_id": "F04",
      "effective_date": "2025-12-01 / 2026-03-31",
      "organization": "Howard County Public School System",
      "market_segment": "Employer — school district",
      "plan_scope": "HCPSS employee health benefits",
      "drug_or_class": "GLP-1 medications used for weight management",
      "indication": "Weight management",
      "change_type": "Phase-out: new-prescription freeze (Dec 1, 2025) then full exclusion (Mar 31, 2026)",
      "access_direction": "Narrowed",
      "pa_transition": "No new approvals after Dec 1, 2025; existing coverage ended Mar 31, 2026; members advised to discuss alternatives with prescribers",
      "source_title": "HCPSS Ending Coverage of GLP-1 Drugs for Weight Management",
      "source_url": "https://staff.hcpss.org/news/hcpss-ending-coverage-glp-1-drugs-weight-management",
      "last_verified": "2026-07-31",
      "notes": "Sponsor reported three-month spending rose from $485K to more than $3.6 million over two years."
    },
    {
      "event_id": "F05",
      "effective_date": "2025-12-12",
      "organization": "CMS — Medicare GLP-1 Bridge demonstration",
      "market_segment": "Federal — Medicare demonstration",
      "plan_scope": "Medicare-eligible beneficiaries",
      "drug_or_class": "Zepbound KwikPen / Wegovy / Foundayo",
      "indication": "Obesity",
      "change_type": "New-program framework and beneficiary guidance published; drug formulary and eligibility criteria documented",
      "access_direction": "Broadened (new pathway — pending July 1, 2026 launch)",
      "pa_transition": "Separate Bridge authorization process; does not interact with Part D coverage or cost-sharing",
      "source_title": "CMS Medicare Obesity Benefit Demonstration — participant guidance",
      "source_url": "https://www.cms.gov/",
      "last_verified": "2026-07-31",
      "notes": "Drug access under the Bridge begins July 1, 2026 at $50/month. Only the Zepbound KwikPen is available (not single-dose vials or pens)."
    },
    {
      "event_id": "F06",
      "effective_date": "2026-01-01",
      "organization": "Boston College employee prescription plan",
      "market_segment": "Employer — university",
      "plan_scope": "Boston College employees",
      "drug_or_class": "GLP-1 drugs for weight loss",
      "indication": "Weight management",
      "change_type": "Mandatory program participation (Calibrate) + copay increase to $150",
      "access_direction": "Narrowed",
      "pa_transition": "Existing users had until Apr 1, 2026 to enroll in Calibrate to maintain coverage; copay for diabetes uses unchanged",
      "source_title": "Boston College Open Enrollment — Important Changes for 2026",
      "source_url": "https://www.bc.edu/bc-web/offices/human-resources/sites/employee-handbook/benefits/open-enrollment.html",
      "last_verified": "2026-07-31",
      "notes": "BC said the change was intended to mitigate cost while retaining a benefit that may help employees and reduce longer-term medical costs."
    },
    {
      "event_id": "F07",
      "effective_date": "2026-01-01",
      "organization": "Harvard-sponsored BCBS and HUGHP plans",
      "market_segment": "Employer — university",
      "plan_scope": "Harvard employee health plans",
      "drug_or_class": "Wegovy / Zepbound / Saxenda",
      "indication": "Weight management",
      "change_type": "EncircleRx program mandatory; BMI/comorbidity criteria tightened; new authorization required for existing users",
      "access_direction": "Narrowed",
      "pa_transition": "New authorization and 9amHealth program enrollment required even for existing users; existing diabetes guidelines unchanged",
      "source_title": "2026 GLP-1 Clinical Change and Coverage Requirements FAQs",
      "source_url": "https://harvie.harvard.edu/sites/g/files/omnuum12046/files/2025-10/GLP1_Clinical_Changes_FAQ.pdf",
      "last_verified": "2026-07-31",
      "notes": "Four weigh-ins and four app engagements required per rolling 30-day window; BMI ≥32 or BMI 27–31 with at least two documented weight-related conditions."
    },
    {
      "event_id": "F08",
      "effective_date": "2026-01-01",
      "organization": "Mayo Clinic employee medical plan",
      "market_segment": "Employer — health system",
      "plan_scope": "Mayo Clinic employees",
      "drug_or_class": "Weight-management medications (GLP-1s)",
      "indication": "Weight management",
      "change_type": "Prior lifetime maximum lifted; practice-led Mayo weight-management program required",
      "access_direction": "Broadened",
      "pa_transition": "Access increased for plan year 2026; members must participate in Mayo's practice-led weight-management program; plan said it would help prevent coverage gaps",
      "source_title": "Mayo Clinic Open Enrollment 2026 Guide",
      "source_url": "https://mcforms.mayo.edu/mc6200-mc6299/mc6213.pdf",
      "last_verified": "2026-07-31",
      "notes": "Mayo described this as a 2026-only approach subject to reassessment for 2027."
    },
    {
      "event_id": "F09",
      "effective_date": "2026-01-01",
      "organization": "Ohio State University Faculty and Staff Health Plan",
      "market_segment": "Employer — university",
      "plan_scope": "OSU faculty and staff",
      "drug_or_class": "GLP-1 medications and generic equivalents",
      "indication": "Weight management",
      "change_type": "Coverage limited to type 2 diabetes indication",
      "access_direction": "Narrowed",
      "pa_transition": "Subject to 2026 plan exclusion for non-diabetes uses; type 2 diabetes indication retained",
      "source_title": "OSU Faculty and Staff Health Plan Specific Plan Details Document",
      "source_url": "https://hr.osu.edu/wp-content/uploads/medical-spd.pdf",
      "last_verified": "2026-07-31",
      "notes": "Plan documents did not state a separate economic rationale."
    },
    {
      "event_id": "F10",
      "effective_date": "2026-01-01",
      "organization": "State of Michigan SHP PPO and State HDHP",
      "market_segment": "Employer — state",
      "plan_scope": "Michigan state employee prescription plans",
      "drug_or_class": "Saxenda / Wegovy / Zepbound and other GLP-1 inhibitors",
      "indication": "Weight management and obstructive sleep apnea",
      "change_type": "Indication exclusion",
      "access_direction": "Narrowed",
      "pa_transition": "Existing prior authorizations for weight management or sleep apnea ended Dec 31, 2025; members directed to discuss alternatives with prescribers",
      "source_title": "What's New in Benefits — State Health Plan Prescription Drug Coverage",
      "source_url": "https://www.michigan.gov/mdcs/employeebenefits/boe/enroll-elig/parts",
      "last_verified": "2026-07-31",
      "notes": "Diabetes and qualifying cardiovascular diagnoses were retained."
    },
    {
      "event_id": "F11",
      "effective_date": "2026-01-01",
      "organization": "CMS Medicare Part D — cardiovascular risk-reduction indication pathway",
      "market_segment": "Federal — Medicare Part D",
      "plan_scope": "Medicare Part D plan sponsors",
      "drug_or_class": "Wegovy (semaglutide) for cardiovascular risk reduction",
      "indication": "Cardiovascular risk reduction",
      "change_type": "Coverage authorization under Part D for FDA-approved cardiovascular indication",
      "access_direction": "Broadened",
      "pa_transition": "Part D plans may cover semaglutide when prescribed for cardiovascular risk reduction; separate from the weight-management coverage exclusion that applies to most Part D drug coverage",
      "source_title": "CMS Medicare Part D prescription drug benefit guidance",
      "source_url": "https://www.cms.gov/medicare/prescription-drug-coverage",
      "last_verified": "2026-07-31",
      "notes": "This pathway is distinct from the Medicare GLP-1 Bridge. It applies to the cardiovascular indication approved by the FDA in March 2024. Zepbound (tirzepatide) received an FDA-approved sleep-apnea indication; Part D plans may also cover it for that indication."
    },
    {
      "event_id": "F12",
      "effective_date": "2026-06-01",
      "organization": "Kansas Medicaid fee-for-service",
      "market_segment": "Medicaid",
      "plan_scope": "Kansas Medicaid fee-for-service members",
      "drug_or_class": "GLP-1 drugs for weight management",
      "indication": "Obesity — weight management",
      "change_type": "PA criteria tightened: documentation and BMI threshold requirements adjusted",
      "access_direction": "Narrowed",
      "pa_transition": "Prior authorizations on file subject to review against updated criteria; new requests must meet updated documentation standards",
      "source_title": "Kansas Medicaid PA criteria / KFF Medicaid prescription drug state indicator",
      "source_url": "https://www.kff.org/medicaid/state-indicator/medicaid-prescription-drugs/",
      "last_verified": "2026-07-31",
      "notes": "Source: state PA form and KFF Medicaid coverage tracking. BMI threshold cited in WPG Medicaid GLP-1 prior authorization research."
    },
    {
      "event_id": "F13",
      "effective_date": "2026-07-01",
      "organization": "CMS Medicare GLP-1 Bridge demonstration",
      "market_segment": "Federal — Medicare demonstration",
      "plan_scope": "Medicare-eligible beneficiaries",
      "drug_or_class": "Zepbound KwikPen / Wegovy / Foundayo",
      "indication": "Obesity",
      "change_type": "Drug access begins at $50 per month; new federal access pathway",
      "access_direction": "Broadened (new pathway)",
      "pa_transition": "Separate Bridge authorization process; does not interact with Part D coverage or cost-sharing; only the Zepbound KwikPen is available (not single-dose vials or pens)",
      "source_title": "CMS Medicare Obesity Benefit Demonstration",
      "source_url": "https://www.cms.gov/",
      "last_verified": "2026-07-31",
      "notes": "Bridge program is a CMS demonstration operating outside the Part D benefit. Foundayo (FDA-approved tirzepatide oral) is also included. CMS states the Bridge is not a Part D formulary change."
    },
    {
      "event_id": "F14",
      "effective_date": "2026-07-01",
      "organization": "Express Scripts National Preferred Formulary (NPF)",
      "market_segment": "Commercial PBM",
      "plan_scope": "Express Scripts commercial plan sponsors using the NPF",
      "drug_or_class": "Zepbound (tirzepatide)",
      "indication": "Weight management",
      "change_type": "Formulary revision: Zepbound pens listed as preferred; KwikPens and vials excluded",
      "access_direction": "Mixed — presentation-level",
      "pa_transition": "Not stated; plan sponsor benefit documents control; Express Scripts states not every plan covers every listed NPF medication",
      "source_title": "Express Scripts 2026 National Preferred Formulary Update",
      "source_url": "https://www.express-scripts.com/",
      "last_verified": "2026-07-31",
      "notes": "Zepbound pens preferred as alternatives; Zepbound KwikPens and vials excluded. Member benefit materials from the plan sponsor govern actual coverage."
    },
    {
      "event_id": "F15",
      "effective_date": "2026-07-01",
      "organization": "University of Minnesota employee medical plans",
      "market_segment": "Employer — university",
      "plan_scope": "University of Minnesota employees",
      "drug_or_class": "Wegovy / Zepbound single-dose pens and vials",
      "indication": "Weight management",
      "change_type": "Product substitution: pens and vials transitioned to Zepbound KwikPen",
      "access_direction": "Access maintained — formulary change",
      "pa_transition": "Existing authorizations transferred automatically; new prescription required; university stated there would be no coverage gap; pen needles covered on formulary",
      "source_title": "GLP-1 Coverage Update: What to Expect July 1",
      "source_url": "https://hr.umn.edu/HR-Updates/GLP-1-Coverage-Update-What-Expect-July-1",
      "last_verified": "2026-07-31",
      "notes": "University described the substitution as supporting long-term access and easier treatment management."
    },
    {
      "event_id": "F16",
      "effective_date": "2026-10-01",
      "organization": "CVS Health commercial template formularies",
      "market_segment": "Commercial PBM",
      "plan_scope": "CVS Caremark commercial plan sponsors using most common template formularies",
      "drug_or_class": "Zepbound (tirzepatide)",
      "indication": "Weight management",
      "change_type": "Preferred status restored; returns as additional preferred option",
      "access_direction": "Broadened",
      "pa_transition": "Not stated; plan sponsors retain discretion to customize coverage; announcement does not specify presentation",
      "source_title": "CVS Health formulary announcement",
      "source_url": "https://www.cvshealth.com/",
      "last_verified": "2026-07-31",
      "notes": "Announcement does not identify the Zepbound presentation covered. Plan sponsor benefit documents govern."
    }
  ]
}