As GLP-1 medications, like Ozempic, continue to gain attention for their role in managing chronic conditions, HR and employee benefits professionals are increasingly fielding questions about coverage—including for off-label uses like treating Polycystic Ovarian Syndrome (PCOS).
Understanding the clinical rationale and insurance landscape surrounding GLP-1s for PCOS can help your team better support employees navigating complex health needs. Collaborating with a pharmacy benefits manager (PBM) can further strengthen this strategy by uncovering cost-effective coverage options, streamlining access to treatment, and ensuring alignment with broader health plan goals.
Understanding PCOS
PCOS affects an estimated 1 in 10 women of reproductive age. It’s a hormonal disorder that can lead to symptoms such as weight gain, acne, hair loss, and infertility. More critically, PCOS is associated with long-term risks including type 2 diabetes, cardiovascular disease, and endometrial cancer.
A key driver of PCOS symptoms is insulin resistance, which leads to elevated insulin levels and increased production of hormones like testosterone. Ozempic (semaglutide) and other GLP-1 receptor drugs approved for type 2 diabetes mimic a naturally occurring hormone that helps improve insulin sensitivity and regulate blood sugar levels.
By improving insulin sensitivity, Ozempic may indirectly reduce testosterone production, offering potential symptom relief for individuals with PCOS. While promising, this use is considered off-label, meaning it is not FDA-approved for PCOS treatment.
Insurance Coverage: What’s Typically Allowed
Most health plans limit coverage of Ozempic and the other GLP-1 medications to FDA-approved indications—primarily type 2 diabetes and, in some cases, chronic weight management. Despite emerging clinical interest in GLP-1 therapies for PCOS, manufacturers have not submitted formal studies to the FDA for this use. As a result, PBMs and insurers generally do not cover these therapies for PCOS.
This presents a challenge for employees seeking access to the medication for PCOS-related symptoms, and it’s where HR and benefits teams can play a supportive role. Offering education and resources about prior authorizations, covered alternatives, and cash pay options can help employees weigh their options and determine the best strategy for their care.
Ask about the prior authorization criteria in place for GLP-1s to determine whether PCOS treatment would be covered under your plan. If off-label use for PCOS is not an approved use, encourage your employees to discuss alternative treatment options with their provider. Members can also explore options to access the GLP-1 medications at a discounted cash price directly through the manufacturer’s website or TrumpRx.
Supporting Employees Through Complex Care Decisions
As healthcare needs become more nuanced, HR and benefits professionals are uniquely positioned to guide employees through coverage challenges—particularly when it comes to off-label treatments like GLP-1s for PCOS.
By staying informed about the clinical rationale and coverage pathways, you can empower employees to advocate for their health. At the same time, providing education and strategies for your employees ensures your benefits remain inclusive, responsive, and aligned with the evolving needs of your workforce.
Managing rising pharmacy costs while navigating complex pharmaceutical developments is challenging, but you don’t have to do it alone. The Holmes Murphy Pharmacy team can help ensure your strategy is aligned with your budget and the unique needs of your employees. Contact us today to get started.
