A 25-question structured assessment evaluating readiness to make and govern a GLP-1 coverage decision across coverage criteria, prior authorisation, budget impact, clinical outcome conditions, and evidence governance. Designed for payers, with a provider and health-system perspective.
5 domains
25 questions
Approximately 15 minutes
Payer or provider perspective
Self-assessment version. Available as a facilitated Full Diagnostic with independent budget impact modelling, coverage criteria design, and a board-ready GLP-1 decision framework.
Several questions have payer-specific and provider-specific variants reflecting different positions in the GLP-1 coverage decision.
Section 1 of 50% complete
Section 1 of 5
Coverage Criteria Design
Evaluates whether your organisation has framed a deliberate, evidence-based GLP-1 coverage position with clearly specified eligibility, rather than an inherited or default formulary status.
Has your organisation defined an explicit, documented coverage position for GLP-1 receptor agonists, distinguishing the obesity indication from the diabetes indication of the same molecules, rather than relying on an inherited or default formulary status?
Strong - 3 pointsA deliberate, documented coverage position exists, with the obesity and diabetes indications explicitly and separately addressed.
Partial - 2 pointsA position exists but is partial, or does not clearly separate the obesity and diabetes indications.
Weak - 0 pointsThere is no deliberate position. Coverage status is inherited or default, made without a structured decision.
Question 2
Are the clinical eligibility criteria for coverage clearly specified, including BMI thresholds and comorbidity requirements, and aligned to a defensible evidence base rather than set arbitrarily?
Strong - 3 pointsEligibility criteria are specified, evidence-aligned, and documented, including BMI and comorbidity requirements.
Partial - 2 pointsCriteria exist but are loosely defined or not clearly evidence-based.
Weak - 0 pointsNo clear clinical eligibility criteria have been defined.
Question 3
Has your organisation determined how it will handle the same molecule being prescribed for diabetes (typically covered) versus obesity (often contested), including guarding against indication shifting to obtain coverage?
Does your clinical governance address the same molecule being prescribed for diabetes versus obesity, ensuring prescribing indication is documented accurately rather than selected to obtain coverage?
Strong - 3 pointsThe dual-indication issue is explicitly addressed with controls against indication shifting.
Partial - 2 pointsThe issue is recognised but controls are incomplete.
Weak - 0 pointsThe dual-indication issue has not been addressed.
Question 4
Is your coverage position benchmarked against how comparable markets and payers have approached GLP-1 coverage, learning from their experience rather than deciding in isolation?
Strong - 3 pointsThe position is informed by structured analysis of comparable market experience, including where others erred.
Partial - 2 pointsSome awareness of other markets exists but it has not shaped the position systematically.
Weak - 0 pointsThe position has been formed without reference to comparable market experience.
Question 5
Does the coverage decision sit within a clear governance authority, with the appropriate clinical, actuarial, and executive input, rather than being made informally at a single functional level?
Strong - 3 pointsThe decision is made through a defined governance process with clinical, actuarial, and executive input.
Partial - 2 pointsSome cross-functional input exists but the governance is informal.
Weak - 0 pointsThe decision is or would be made informally at a single functional level.
Section 2 of 5
Prior Authorisation Architecture
Tests whether GLP-1 coverage is gated by a prior authorisation process that is clinically sound, fair on appeal, administratively sustainable at scale, and consistent with your coverage criteria.
Tests against: Ungated Approval · Unsustainable Process
Question 6
Is there a defined prior authorisation process for GLP-1 coverage, specifying the clinical documentation and criteria that must be met before approval?
Strong - 3 pointsA structured prior authorisation process with clear criteria and documentation requirements is in place.
Partial - 2 pointsA prior authorisation process exists but is loosely defined or inconsistently applied.
Weak - 0 pointsThere is no defined prior authorisation process for these drugs.
Question 7
Do the authorisation criteria include any required prior steps, such as documented lifestyle intervention or other therapy, where clinically and contractually appropriate?
Strong - 3 pointsPrior-step requirements are defined where appropriate, with clear clinical rationale and documentation.
Partial - 2 pointsSome prior-step logic exists but is incomplete or not consistently required.
Weak - 0 pointsNo prior-step requirements are defined.
Question 8
Is there a clear, fair appeals process for declined authorisations, recognising that a significant proportion of initial denials are clinically legitimate on review?
Strong - 3 pointsA defined appeals process exists, is communicated, and is resourced to handle volume fairly.
Partial - 2 pointsAn appeals process exists but is unclear, slow, or under-resourced.
Weak - 0 pointsThere is no defined appeals process for declined authorisations.
Question 9
Is the prior authorisation process designed to be administratively sustainable at the volume GLP-1 demand generates, rather than a manual process that will be overwhelmed?
Strong - 3 pointsThe process is designed for scale, with the capacity and systems to handle high authorisation volume.
Partial - 2 pointsThe process may struggle at the volume expected but has some capacity.
Weak - 0 pointsThe process is manual and would be overwhelmed by GLP-1 authorisation volume.
Question 10
Are prior authorisation criteria consistent with the clinical eligibility criteria in your coverage position, so that gating and coverage form a coherent whole rather than contradicting each other?
Strong - 3 pointsAuthorisation criteria and coverage criteria are fully aligned and mutually consistent.
Partial - 2 pointsThere is broad alignment but some inconsistencies exist.
Weak - 0 pointsAuthorisation and coverage criteria are not aligned or have not been reconciled.
Section 3 of 5
Budget Impact & Actuarial Modelling
Evaluates whether the financial consequence of the coverage decision has been modelled rigorously across the eligible population, accounting for awareness-driven demand, therapy duration, and the evolving price environment.
Has your organisation modelled the budget impact of its GLP-1 coverage position across the eligible population, rather than treating it as an incremental formulary addition?
Strong - 3 pointsA full budget impact model exists, projecting cost across the eligible population under the coverage position.
Partial - 2 pointsSome cost estimation has been done but it is partial or not population-based.
Weak - 0 pointsNo budget impact modelling has been conducted.
Question 12
Does the budget model account for demand that is driven by consumer awareness and social momentum, not only by clinical referral, recognising that GLP-1 uptake can rise faster than traditional prescribing models predict?
Strong - 3 pointsThe model explicitly incorporates awareness-driven and elastic demand, not only referral-based projection.
Partial - 2 pointsThe model uses traditional prescribing assumptions with limited adjustment for awareness-driven demand.
Weak - 0 pointsDemand is modelled, if at all, on traditional prescribing patterns that understate GLP-1 uptake.
Question 13
Does the model account for the extended, potentially indefinite duration of therapy and the recurring nature of the cost, rather than assuming a bounded treatment course?
Strong - 3 pointsDuration of therapy and cost recurrence, including regain-driven continuation, are built into the model.
Partial - 2 pointsDuration is considered but not rigorously modelled.
Weak - 0 pointsThe model assumes a bounded course and understates the recurring liability.
Question 14
Is the evolving price trajectory of GLP-1 drugs, including manufacturer list price changes and negotiation potential, incorporated into the financial planning?
Strong - 3 pointsThe price trajectory and negotiation potential are actively incorporated and updated in planning.
Partial - 2 pointsPrice is included at current levels but the trajectory is not modelled.
Weak - 0 pointsThe evolving price environment is not reflected in planning.
Question 15
Has the budget impact been stress-tested against scenarios of higher-than-expected uptake, and are the financial and premium implications understood at board level?
Has the financial impact of GLP-1 demand on your organisation, including private-pay patients presenting for related care, been assessed and understood at leadership level?
Strong - 3 pointsScenario stress-testing has been done and the implications are understood at board or leadership level.
Partial - 2 pointsSome scenario analysis exists but is not fully understood at leadership level.
Weak - 0 pointsNo scenario stress-testing has been conducted.
Section 4 of 5
Clinical Outcomes & Discontinuation Conditions
Tests whether the coverage decision confronts the actual clinical behaviour of the therapy: response criteria, discontinuation and regain, monitoring, and its place in the broader obesity and population health strategy.
Tests against: Approval Without Follow-Up · Ignored Regain
Question 16
Does your coverage position define clinical response criteria, specifying what constitutes an adequate response and what happens to coverage if response is inadequate?
Strong - 3 pointsResponse criteria are defined, with clear consequences for continued coverage when response is inadequate.
Partial - 2 pointsResponse is considered but criteria and consequences are not clearly defined.
Weak - 0 pointsNo response criteria are defined.
Question 17
Are discontinuation and stopping rules specified, addressing when therapy should be stopped and how the well-documented weight regain on cessation is managed?
Strong - 3 pointsDiscontinuation and stopping rules are specified, with regain management explicitly addressed.
Partial - 2 pointsSome discontinuation logic exists but regain management is not addressed.
Weak - 0 pointsNo discontinuation or stopping rules have been specified.
Question 18
Is there a defined approach to the clinical monitoring of covered patients, including adherence, side effects, and outcomes, rather than approval without follow-up?
Strong - 3 pointsA clinical monitoring approach covering adherence, safety, and outcomes is defined and operational.
Partial - 2 pointsSome monitoring exists but is partial or not systematically applied.
Weak - 0 pointsThere is no defined clinical monitoring of covered patients.
Question 19
Does the coverage position account for the expanding clinical evidence, including cardiovascular and other outcome benefits, in how it values and justifies the therapy?
Strong - 3 pointsThe position explicitly incorporates the broader outcome evidence in its clinical and value rationale.
Partial - 2 pointsThe broader evidence is acknowledged but not integrated into the position.
Weak - 0 pointsThe position does not account for the expanding outcome evidence.
Question 20
Is GLP-1 coverage positioned within the organisation broader obesity and chronic disease strategy, including its relationship to bariatric surgery and to the population health agenda, rather than as an isolated drug decision?
Strong - 3 pointsGLP-1 coverage is integrated into the broader obesity, chronic disease, and population health strategy.
Partial - 2 pointsSome connection to broader strategy exists but the integration is partial.
Weak - 0 pointsGLP-1 coverage is treated as an isolated drug decision, disconnected from broader strategy.
Section 5 of 5
Governance & Strategic Positioning
Evaluates whether the decision is governed as a board-level strategic matter, with evidence monitoring, reputational management, competitive positioning, and overall coherence across the dimensions.
Is there a defined mechanism to monitor the expanding GLP-1 evidence base and adjust the coverage position deliberately as new indications and data emerge, rather than being overtaken by events?
Strong - 3 pointsA defined evidence-monitoring and position-review mechanism is in place and operating.
Partial - 2 pointsThe need to revisit the position is recognised but no defined mechanism exists.
Weak - 0 pointsThere is no mechanism to monitor evidence and adjust the position.
Question 22
Has the GLP-1 coverage decision been taken to, or is it governed by, the board or an appropriate executive committee, given its financial and reputational scale?
Strong - 3 pointsThe decision is governed at board or senior executive level with appropriate visibility.
Partial - 2 pointsLeadership is aware but the decision is not formally governed at that level.
Weak - 0 pointsThe decision has not reached board or senior executive governance.
Question 23
Has your organisation assessed the reputational and member-relations dimension of the decision, including how a coverage position, or a change to it, will be communicated and defended?
Strong - 3 pointsThe reputational and communication dimension is assessed with a defined approach to member relations.
Partial - 2 pointsThe dimension is recognised but no clear communication approach exists.
Weak - 0 pointsThe reputational and member-relations dimension has not been assessed.
Question 24
Has your organisation considered the competitive and market-positioning implications of its GLP-1 coverage decision relative to other payers and to member expectations?
Has your organisation considered how GLP-1 demand and coverage patterns affect its service model, referral pathways, and positioning in obesity care?
Strong - 3 pointsThe competitive and positioning implications have been explicitly considered in the decision.
Partial - 2 pointsPositioning is loosely considered but not integral to the decision.
Weak - 0 pointsThe competitive and positioning implications have not been considered.
Question 25
Overall, is the GLP-1 coverage decision being made deliberately, as a structured strategic decision with each dimension set coherently, rather than by default or in isolated parts?
Strong - 3 pointsThe decision is deliberate and structured, with the dimensions set coherently as a whole.
Partial - 2 pointsThe decision is partially structured but some dimensions are set in isolation or by default.
Weak - 0 pointsThe decision is being made by default or in disconnected parts, without coherent structure.
GLP-1 Coverage Decision Gate - Results
Your GLP-1 Decision Readiness Profile
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Domain Breakdown
Coverage Criteria Design
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Prior Authorisation
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Budget Impact Modelling
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Clinical Conditions
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Governance & Positioning
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Indicative Findings
Calculating...
This self-assessment shows the methodology. The facilitated diagnostic goes further.
A facilitated HealthElevate GLP-1 diagnostic includes independent budget impact modelling against your population, coverage criteria and prior authorisation design, and a board-ready decision framework with an evidence-monitoring mechanism.
The GLP-1 Coverage Decision: The Spend Shock Saudi Insurers Cannot Improvise
The analytical context behind this instrument: why demand arrived before policy, how the cardiovascular evidence is reclassifying the drugs, and why the decision cannot be deferred or improvised.