TIER 2 · COVERAGE DECISIONS · GLP-1 AND SPECIALTY
Make the Coverage Call
Before Someone Makes It for You.
A 2-page printable record that sorts your 2027 GLP-1 and specialty coverage decisions into the three that must be settled before open enrollment materials print and the two that can wait with the right contract language. Free download. Sent to your inbox.
The 3 decisions members will read in print, and why they cannot wait
The 2 that can move mid-year, and the clause each one needs
Paste-ready criteria request to send your PBM or UM vendor
Documentation fields that turn each call into a prudent process
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Built by Prescription Benefit Solutions, an independent pharmacy benefits consultancy. In 2025: 132 pharmacy benefit reviews for self-funded employers, averaging $469,000 in contracted savings per client.
A complete audit framework you can run in half a day.
WHAT IS IN THE WORKSHEET
PASS 03
The Criteria Request, Paste-Ready
Which GLP-1 is preferred and the operational detail of the criteria can legitimately move during the year, but only if the contract governs the move. The record specifies the language for each: advance written notice of any preferred-product change, a comparison on net cost per member rather than rebate yield, a transition rule for stable members, and no change to criteria applied in the plan's name without written approval.
PASS 01
The Three Decisions Members Will Rea
Coverage by indication, who qualifies, and the continuation rule all appear in the enrollment guide, the summary of benefits, or the plan document, so they have to be settled before those print. The record walks each one: deciding GLP-1 coverage for diabetes and weight management separately and in plan-document language, setting eligibility criteria including the age floor adult-written criteria sets often omit, and deciding the reauthorization interval, the continuation threshold, and what happens on January 1 to members already on therapy.
PASS 02
The Two That Can Wait, With a Clause
Which GLP-1 is preferred and the operational detail of the criteria can legitimately move during the year, but only if the contract governs the move. The record specifies the language for each: advance written notice of any preferred-product change, a comparison on net cost per member rather than rebate yield, a transition rule for stable members, and no change to criteria applied in the plan's name without written approval.
ACTION PLAN
Document the Call
For each decision the record captures the date, the options considered, the claims data reviewed, the clinical input, a cost range for each option, the rationale, and the review date. Under ERISA the process is the protection: the same outcome reached by default is harder to defend than the same outcome reached on purpose. An October, November, February sequence ends with the first read of January approvals against what the budget assumed.