By Jason Peterson, RPh; Beckie Fenrick, PharmD, MBA; and Emily Crisano, PharmD, RPh
The American Diabetes Association (ADA) recently released its 2025 Standards of Care in Diabetes—a comprehensive set of evidence-based recommendations designed to guide the prevention, diagnosis and management of diabetes. These guidelines are considered the gold standard by clinicians and health systems nationwide.
For plan sponsors, the latest version comes with a critical takeaway: utilization is about to rise—and so are pharmacy costs. Expanded eligibility for high-cost drugs, new recommendations for emerging therapies, and broader use of continuous glucose monitors all have implications for your pharmacy benefit strategy.
Here’s what changed, why it matters, and how to stay ahead.
Key Changes Driving Utilization and Spend
1. Expanded CGM Coverage for More T2D Patients
The ADA now recommends continuous glucose monitor (CGM) use not only for all insulin-treated patients, but also for adults with type 2 diabetes (T2D) taking any glucose-lowering medication. This reflects growing evidence that CGMs support better outcomes even in non-insulin users.
Common CGMs can cost upwards of $4,500 annually per patient. With Medicare coverage still lagging behind these guidelines, plan sponsors should anticipate increased CGM utilization and potential pressure to align coverage with these clinical best practices.
2. GLP-1s and GIP/GLP-1s for Cardiometabolic Conditions—Not Just Diabetes
GLP-1 receptor agonists and dual GIP/GLP-1 agents like tirzepatide are now recommended across a wider array of conditions, including:
- Atherosclerotic cardiovascular disease (ASCVD)
- Heart failure with preserved ejection fraction (HFpEF)
- Chronic kidney disease (CKD)
- Metabolic dysfunction-associated steatotic liver disease (MASLD)
- Obesity and weight maintenance
These therapies are now positioned as first-line interventions, even for patients with controlled A1C. This shift is expected to drive long-term utilization of GLP-1s beyond their traditional role in glucose management. With many of these medications priced between $12,000-$14,000 annually, plan sponsors will need to reassess how their strategy supports both access and affordability.
3. SGLT2 Inhibitors Recommended More Broadly
The ADA now recommends SGLT2 inhibitors more widely—not just for lowering A1C, but for preventing heart failure hospitalizations and slowing the progression of chronic kidney disease (CKD).
This class was once reserved for patients with uncontrolled blood sugar. Now, patients with heart failure or CKD may be prescribed an SGLT2 inhibitor even if their A1C is well controlled. This broader use means plan sponsors should anticipate growth in utilization, with annual costs generally ranging from $7,000-$8,000.
4. New Specialty Drugs
A new therapy was newly included in the guidelines: Rezdiffra for adults with T2D or prediabetes and moderate to advanced MASLD. Though intended for a smaller population, Rezdiffra carries a high price tag—over $50,000 for Rezdiffra 5. Deprioritizing DPP-4 Inhibitors
The ADA now recommends against combining DPP-4 inhibitors with GLP-1 receptor agonists due to a lack of additive benefit. Plan sponsors may want to consider this when optimizing utilization management and targeting low-value spend.
Strategic Takeaways for Plan Sponsors
The 2025 updates mark a turning point in diabetes care—one that prioritizes early, aggressive, and more expensive treatment strategies across multiple disease states.
Plan sponsors should expect:
- A rise in CGM claims from broader eligibility
- Steady growth in GLP-1 and SGLT2 utilization across new populations
- Pressure to cover newly recommended specialty drugs
- A need to reevaluate formularies for clinical alignment and cost-effectiveness
Several of these therapies come with five- and six-figure annual price tags—making even small shifts in eligibility criteria a potential budget concern for plan sponsors.
As clinical best practices evolve, our team of clinical pharmacists and benefit strategists can help you navigate the impact to your plan. From formulary optimization to cost-containment strategies, we’re here to help you stay aligned with care quality and your bottom line.
