5 Things to Know About the Oral GLP-1 Era

The glucagon-like peptide-1 (GLP-1) class has transformed treatment for diabetes and obesity, reshaping utilization patterns and pharmacy spending for payers and employers alike. In December 2025, the FDA approved the first oral GLP-1 weight-loss medication, the Wegovy pill, ushering in a new phase of the GLP-1 era.¹ But although the shift to a pill represents a significant clinical milestone, it does not automatically resolve longstanding issues of cost, access, and utilization management. Here are 5 things to know about the oral GLP-1 era.

1. Oral GLP-1s Expand Choice—Not Necessarily Lower Cost

The FDA cleared the Wegovy pill (Novo Nordisk), a once-daily oral semaglutide 25-mg formulation for chronic weight management, based on 64-week phase 3 trial data showing meaningful weight loss compared with placebo. The approval marked the first time an oral GLP-1 was cleared specifically for weight management in adults with obesity or overweight and at least 1 weight-related comorbidity.

This approval gives patients an alternative to injectable GLP-1s; however, early pricing signals suggest that oral formulations may be priced similarly to existing injectable products, limiting the potential for dramatic cost reductions.² From a manufacturing and logistics standpoint, oral GLP-1s should cost less, Eric Levin, CEO and cofounder of Scripta, explained in an interview. They are easier to produce and that advantage does show up in the cash-pay market. Patients who purchase oral GLP-1s directly from manufacturers or cash-pay platforms may see prices that are a few hundred dollars lower than injectable versions. However, for patients using insurance, Levin noted that oral and injectable GLP-1s are currently priced about the same.

As payers and employers grapple with rising pharmacy expenditures driven by GLP-1 drugs, oral options may expand utilization without substantially easing budget pressures.

2. Utilization Growth Drives Budget Impact

GLP-1 therapies have rapidly become significant drivers of pharmacy spending.³ Even before oral formulations entered the market, plans were reporting that GLP-1s represented a disproportionate share of claims and budget growth. As oral options appeal to patients who are injection-averse, demand is likely to broaden still further, potentially amplifying existing cost pressures in commercial and employer-sponsored benefits.

Clinical trial data demonstrate robust weight-loss outcomes with oral semaglutide. In the phase 3 OASIS 4 trial (NCT05564117), participants receiving the 25-mg pill experienced average weight loss of approximately 16.6% when adherent, a result broadly comparable to injectable semaglutide outcomes seen in prior studies.¹

3. Real-World Adherence and Patient Behavior Remain Uncertain

One key rationale for oral GLP-1s has been the potential for better adherence compared with injectable therapies. Real-world evidence, however, remains limited.⁴ Some oral GLP-1 regimens require strict dosing conditions, such as taking the pill on an empty stomach and avoiding food or drink for a specified period afterward, which may pose daily challenges for patients.⁵

Without robust adherence data outside controlled clinical settings, payers may be cautious about loosening utilization controls or assuming greater long-term persistence relative to injectable alternatives.⁶ The actual value of oral GLP-1s will depend on how patients navigate these real-world behaviors and dosing requirements.

4. Formulary and Utilization Management Strategies Must Adapt

Managed care organizations are already refining utilization management strategies in response to rising GLP-1 utilization, including prior authorization criteria and step therapy rules, to limit initial and ongoing prescribing and control near-term spending.⁷ Prior authorization, step therapy, and documentation of medical necessity are becoming standard approaches to ensure appropriate use and to control spend.

Payers may determine whether oral formulations should be preferred as first-line options or remain subject to step edits requiring trials of injectables or other therapies first.⁸ Pharmacy benefit managers may also leverage oral formulations differently in rebate negotiations and tier placement decisions, potentially affecting cost-sharing and access.

5. Employers Face Pressure to Balance Access and Value

Employers have watched demand for GLP-1 therapies grow alongside concerns about workforce health, productivity, and rising benefit costs. Employer surveys show that high-cost specialty drugs, including GLP-1 receptor agonists, are increasingly viewed as threats to affordability and competitiveness, prompting many employers to reassess coverage decisions.⁹ As oral GLP-1s enter the market, employers may face additional pressure as pill formulations appeal to employees who are hesitant to initiate injectable therapies, potentially broadening utilization and accelerating pharmacy spend growth.

To balance access with fiscal sustainability, employers are increasingly exploring targeted strategies rather than broad, unrestricted coverage. Employers are turning to enhanced eligibility criteria, vendor-managed programs, and integration with lifestyle or weight-management initiatives to better control utilization and assess value, according to the surveys.

The approval of oral GLP-1 therapies marks a notable evolution in obesity management, expanding therapeutic choice beyond injectable options. Although this development could improve uptake among patients who prefer oral medications, the challenges of affordability, adherence, and utilization management are unlikely to disappear.

References

1. Joszt L. FDA approves oral semaglutide as first GLP-1 pill for weight loss. AJMC^®. December 23, 2025. Accessed February 6, 2026. https://www.ajmc.com/view/fda-approves-oral-semaglutide-as-first-glp-1-pill-for-weight-loss
2. Grossi G, Levin E. Oral vs injectable GLP-1 cost-saving strategies: Eric Levin. AJMC. February 5, 2026. Accessed February 6, 2026. https://www.ajmc.com/view/oral-vs-injectable-glp-1-cost-saving-strategies-eric-levin
3. McCormick B. Innovative payment models, holistic Medicaid approaches could improve GLP-1 access, outcomes. AJMC. October 30, 2025. Accessed February 6, 2026. https://www.ajmc.com/view/innovative-payment-models-holistic-medicaid-approaches-could-improve-glp-1-access-outcomes
4. Klein H. Real-world use of GLP-1s yields less weight loss than clinical trials. AJMC. June 10, 2025. Accessed February 6, 2026. https://www.ajmc.com/view/real-world-use-of-glp-1s-yields-less-weight-loss-than-clinical-trials
5. Semaglutide. Drugs.com. Updated January 7, 2026. Accessed February 6, 2026. https://www.drugs.com/semaglutide.html
6. Gleason PP, Urick BY, Marshall LZ, Friedlander N, Qiu Y, Leslie RS. Real-world persistence and adherence to glucagon-like peptide-1 receptor agonists among obese commercially insured adults without diabetes. J Manag Care Spec Pharm. 2024;30(8):860-867. doi:10.18553/jmcp.2024.23332
7. Griauzde D, Carter EW, Oshman L, et al. Understanding insurance coverage policies for incretin mimetics for weight management. Am J Manag Care. 2025;31(7):342-349. doi:10.37765/ajmc.2025.89685
8. Klein H. Top 5 most-read reimbursement content of 2025. AJMC. December 28, 2025. Accessed February 6, 2026. https://www.ajmc.com/view/top-5-most-read-reimbursement-content-of-2025
9. Klein H. Employers eye transparency, data access to confront rising health care costs. AJMC. September 9, 2025. Accessed February 6, 2026. https://www.ajmc.com/view/employers-eye-transparency-data-access-to-confront-rising-health-care-costs