Lifetime Drug Limits (Infertility, GLP-1 Drugs for Weight Loss)

To ensure U-M’s Prescription Drug Plan remains cost-effective for the university and health plan members, a few drugs on the formulary have lifetime maximum limits. This means there is a set amount of refills that members, dependents and other qualified adults (OQAs) can receive of these drugs. 

Infertility Drugs

The Prescription Drug Plan will cover 5 medication fills per lifetime, per family, of the self-administered infertility medications listed below:

  • Bravelle (urofollitropin)
  • Gonal-F (follitropin alfa)
  • Follistim AQ (follitropin)
  • Menopur (menotropins)

What this means: Each time any member of your family receives a fill for one of these drugs, it counts toward a lifetime maximum of 5 fills.

For example, the 5-fill lifetime limit would allow you to fill two orders of Gonal-F and 3 orders of Menopur before exhausting your benefit. After 5 of these medications are filled, in any combination, you will no longer have U-M Prescription Drug Plan coverage. Additional costs for subsequent refills will become your responsibility.

You can, however, use your Flexible Spending Account (FSA) or Health Savings Account (HSA) funds to pay for the drugs after you’ve reached your maximum coverage limit. 

Glucagon-like Peptide 1 Agonist (GLP-1) Drugs

The Prescription Drug Plan will cover a maximum lifetime benefit of two years (24 one-month fills) for any combination of GLP-1 products indicated, and used for, for weight loss. This limit applies to claims filled on or after May 1, 2024. Prior authorization is still required for coverage. Review current coverage criteria in this document; the GLP-1 information is under the section titled "WEIGHT LOSS GLP-1s."

Affected drugs include: 

  • Wegovy (semaglutide)
  • Zepbound (tirzepatide)
  • Saxenda (liraglutide)

What this means: This 24-fill maximum limit applies only to injectable GLP-1 drugs prescribed for a diagnosis of obesity. The limit DOES NOT affect the following:

  • GLP-1 drugs prescribed for a diagnosis of diabetes
  • Weight loss drugs prescribed for a diagnosis of obesity, but administered in oral (pill) form (i.e., Contrave, Qsymia, Xenical, and phentermine.

Medications filled before May 1, 2024 do not count toward the lifetime maximum benefit. You may have up to 24 months of coverage starting on or after May 1, 2024, as long as you continue to meet prior authorization requirements. 

You can use your Flexible Spending Account (FSA) or Health Savings Account (HSA) funds to pay for the drugs after you’ve reached your maximum coverage limit. 

U-M’s goal is to provide coverage for quality, cost-effective medications that contribute to the health of its members. Administrators routinely monitor factors affecting the cost of prescription drugs and will revisit policies as circumstances warrant. 

For More Information

If you have questions about the lifetime maximum coverage limit for the above prescription drugs, contact Magellan Rx/Prime Therapeutics at (888) 272-1346.

Frequently Asked Questions about GLP-1 (Weight Loss) Medication Coverage

In May 2024, the university changed its Prescription Drug Plan coverage of glucagon-like peptide-1 (GLP-1) medication prescribed for weight loss. These drugs are commonly known as Ozempic, Zepbound and Wegovy. View the following frequently asked questions for comprehensive information.

What is a GLP-1 prescription drug?
A glucagon-like peptide-1 (GLP-1) drug is prescribed by a doctor to treat diabetes or obesity. These drugs work in two ways:
  • GLP-1 drugs prescribed for diabetes prompt the body to produce more insulin, which reduces blood glucose (sugar) levels.
  • GLP-1 drugs prescribed for obesity interact with the brain to reduce appetite and signal a feeling of fullness, resulting in reduced calorie intake.
What change was made to the coverage of GLP-1 drugs?
As of May 1, 2024, the U-M Prescription Drug Plan will cover a maximum lifetime benefit of two years (i.e., 24 one-month fills) for any combination of GLP-1 agents when used only for weight loss. This change applies only to coverage for a diagnosis of obesity (weight loss). However, if you take GLP-1s for diabetes, your coverage remains the same. 
I take a GLP-1 drug for diabetes. Is there a limit on my coverage?
No. If you take a GLP-1 injectable for a diagnosis of diabetes, your coverage is not affected by the policy change. 
I take an oral medication for weight loss. Is there a limit on my coverage? 
No. If you take an oral (pill) medication for a diagnosis of obesity, your coverage is not affected by this policy change. Covered oral medications for weight loss include Contrave, Qysmia, Xenical, and phentermine. 
If members reach the 2-year, 24-month fill maximum for a GLP-1 used for weight loss, one of their options is to begin or resume taking oral weight loss medications.
Why was this change made? 
As the use of GLP-1s for weight loss has significantly increased, the cost to U-M has skyrocketed. This cost for a single type of medication is not sustainable. 
Rather than stop covering these drugs entirely, the university enacted a two-year, 24-month lifetime limit. This period allows members to continue to take injectable GLP-1s for weight loss while giving them time to create a plan for their post-GLP-1 health. 
What medications are affected by this change?
The following injectable medications, when prescribed for weight loss only, are affected by the policy change: 
  • Wegovy (semaglutide)
  • Zepbound (tirzepatide)
  • Saxenda (liraglutide)
After I reach the 2-year, 24-month fill maximum, can I pay out-of-pocket for the injectable GLP-1 drug?
You can pay out-of-pocket and/or use your Flexible Spending Account (FSA) or Health Savings Account (HSA) funds.  
How does U-M’s policy on GLP-1 injectables for weight loss compare to other major employers? 
At present, only about 1 in 4 U.S. employers cover GLP-1 drugs prescribed for obesity. Of those, many are examining their coverage policies in light of significant cost increases. 
Will U-M revisit its coverage of injectable GLP-1 drugs in the future?
U-M Prescription Drug Plan administrators routinely monitor the cost, demand and other factors contributing to drug accessibility.