Navigating GLP-1 Access & Prior Authorizations: Amanda Velazquez, MD

With a growing menu of glucagon-like peptide-1 (GLP-1) medications available to treat obesity, health system formularies have to weigh cost and outcomes data for each, explained Amanda Velazquez, MD, director of obesity medicine at the Center for Weight Management and Metabolic Health at Cedars-Sinai Medical Center.

She also discussed what structural changes could help close persistent gaps in equitable access to obesity care, how prior authorization and step therapy requirements affect patients and provider workflows, the trade-offs health systems face with telehealth and digital tools, and what a sustainable, scalable obesity care infrastructure needs to include going forward.

In part 1 of the interview with The American Journal of Managed Care^® (AJMC^®), Velazquez had explained that scaling obesity care requires a multidisciplinary team, standardized protocols, and clear referral pathways so patients don't get lost between primary care, specialists, and procedural teams.

This interview has been edited for clarity and length.

AJMC: GLP-1s now come in multiple options, both injectable and oral. How should health system formulary committees weigh these options against cost and outcomes data?

Velazquez: I think health system formularies need to think about the benefits of these medications as more of a preventive therapy. GLP-1s [glucagon-like peptide-1 receptor agonists] can be effective in multiple ways independent of weight loss, but I think they've gotten boiled down to “take a shot, or take a medicine, and that's all you need to do to turn your health around,” when it's more complicated than that. It requires wraparound care.

Although cost is coming down, I recognize it's still high, and I also recognize that the volume of patients who could qualify for GLP-1s would appear overwhelming to health systems, so putting these drugs on the formulary is probably something systems may hesitate to do, given that. But what medications need to be thought about is the data around uptake of these medications—although 70% of the population is with overweight or obesity,¹ 70% of the population is not going to start taking a GLP-1, nor would all of them qualify. There are a lot of other variables in whether someone goes on that agent. My point is that uptake of these medications isn't going to match the size of the existing population that has the disease of overweight or obesity, nor will everyone necessarily qualify for it.

If health systems were to target certain populations for formulary coverage, I think it would be very beneficial, especially for employee health, thinking about absenteeism and presenteeism, where we see promising data for patients able to improve their health and, in turn, be a better workforce. It's about balancing that with the outcomes data that comes with it—improvement in functionality and quality of life, and improvements not only in weight loss but, more importantly, in obesity-related conditions: fatty liver, reduced risk of heart disease and stroke, peripheral arterial disease, obstructive sleep apnea—the list goes on. I think this is a milestone in medical history, and health systems that understand this would appreciate the outcomes data and the fact that this could be very meaningful for patients, especially particular patient populations, if they wanted to start there initially for formulary coverage.

AJMC: Equitable access to care in general is a persistent challenge across health care, and this treatment has traditionally ended up going to patients who have better insurance and access to resources. What structural changes could be implemented to help close those kinds of gaps?

Velazquez: I think education is key, at multiple levels. Education provided to our health care professionals, so they understand how to get access for patients who are historically underserved and know how to get coverage for them, is one piece. The second is working with your internal pharmacy team. We've made strong relationships with our Cedars-Sinai specialty pharmacy team, which has helped on both ends: helping patients gain access to these medications through prior authorization support and clinical pharmacists who see patients in the clinic to teach them how to administer their medications, improve adherence through care-related education, and answer practical questions, such as how to manage their medications while traveling.

Populations that are often disadvantaged in getting access to these medications can be helped significantly by an informed health care team that advocates and has the knowledge to exhaust every avenue for helping these patients obtain access to obesity management medications. Making that information ubiquitous across the health system, prioritizing its distribution, and having resources like a strong internal pharmacy team to support clinicians would help these groups get access to this care.

AJMC: How do things like prior authorization and step therapy requirements affect patient access and provider workflows, and what strategies successfully overcome those challenges?

Velazquez: In many ways, these are ultimately red tape for patients. The burden falls not only on patients but also on the health care team, especially if that team is already bogged down, understaffed, or has limited knowledge about how to navigate prior authorization and step therapy requirements. It can lead to discontinuation of the medication or patients never successfully initiating therapy, which is a real loss, and unfortunately, this happens quite often for patients in the US health care system.

Nonetheless, this is the system, so how do we navigate it? I think the most important part is being informed: education, a strong pharmacy team to support clinicians, and back-office support, because working through prior authorizations and step therapy requirements for every patient is extremely time-intensive. What we do for our program is protocolize a lot of this to navigate the red tape and leverage the expertise of multiple types of team members (nursing, APPs, pharmacists, pharmacy technicians, patient navigators, and physicians) to help in the process.

One example is the Bridge program: we understand that under the Bridge program, for Medicare patients with Part D, patients could qualify, through December 31, 2027, for certain GLP-1 agents—a mix of oral and injectable—depending on whether they meet criteria.² The moment a clinician, a physician, or an APP [advanced practice provider] enters that order—say, for tirzepatide [Zepbound; Eli Lilly], an injectable—the order gets denied from Medicare when submitted for the Bridge program. It's an automatic denial with an automatic prior authorization form. For health systems or clinician teams that aren't aware that's the automatic process, that's already one step working against them.

What's critical is knowing how to work through that. Our team has created a protocol: we already know it's going to bounce back, we know what the follow-up questions will be, and we fill out a pre-templated form in advance, so our pharmacy team has that information up front and can bounce back with the answers we want to provide as soon as the denial comes in, to make it a smoother process. Otherwise, it becomes a back-and-forth that's very time- and resource-intensive.

AJMC: Is your program utilizing telehealth and digital tools? How should health systems think about the trade-offs between potentially better access and the equity issues that can arise with this technology?

Velazquez: Cedars-Sinai has a program called CS Connect, a purely virtual weight management program for patients looking for routine weight management care. It has 24-hour access and can serve any patient, even one who isn't otherwise a Cedars-Sinai patient. That's one example. Our clinical program, the Center for Weight Management and Metabolic Health here at Cedars-Sinai, is our brick-and-mortar program, but it also includes a telehealth arm where we see patients virtually for follow-up visits, depending on their needs. I think that has helped improve patient access, especially for those who live farther away from the Los Angeles County area.

For digital tools, we've leveraged various tools in the past, and it depends on the patient, because our care is very individualized. That's ultimately the goal and the North Star for obesity care: individualized, personalized care. That said, the trade-off with some digital tools is that they're not always the most reliable, so you have to take that with a grain of salt and look more at the trends.

I think with telehealth visits, a risk is losing a little bit of that personal touch that's important in medicine and that we want to continue providing. Health care systems should recognize that certain medical situations require in-person care and educate patients accordingly. For example, we require patients to be seen in person for initial consults, if able, because we think getting that in-person data—vitals, anthropometrics such as waist, hip, and neck circumference measurements, bioimpedance assessment, lab work, and physical exam—is a very necessary step in treating medically complex patients living with obesity.

AJMC: Looking toward 2027 and beyond, what does a sustainable, scalable obesity care infrastructure need to include that most systems don't have today?

Velazquez: I'd say that most scalable obesity care infrastructures really need a comprehensive team of health care professionals and a systemized approach to how they manage patients with obesity treatment—understanding when to escalate care, when to flag a provider about side effects from a pharmacologic agent, and who the go-to resources are, within the health system or externally in the community, for presentations that may need more specialized care. For example, if a patient develops an eating disorder while on pharmacologic therapy for obesity treatment, who would we refer them to? Who is their support?

I think that right now, the main priority is making sure there's a multidisciplinary team in place to deliver whole-person care, and that there are protocols in place to understand when to flag for more intensive care that some patients may need.

References

1. National Institute of Diabetes and Digestive and Kidney Diseases. Overweight & obesity statistics. NIDDK. Reviewed September 2021. Accessed September 25, 2026. https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity

2. Halpern L. Medicare's new GLP-1 Bridge Program: what pharmacists need to know before dispensing. July 9, 2026. Accessed September 25, 2026. https://www.pharmacytimes.com/view/medicare-s-new-glp-1-bridge-program-what-pharmacists-need-to-know-before-dispensing