With
roughly
two
in
five
U.S.
adults
affected
by
obesity,
GLP-1
drugs
have
emerged
as
a
promising
solution
—
but
their
steep
price
remains
a
significant
hurdle.
For
instance,
GLP-1
drugs
have
a
list
price
ranging
from
$936
to
$1,349
before
insurance
coverage,
rebates
or
other
discounts
are
applied.
Given
the
expense,
several
insurers
have
decided
to
stop
covering
GLP-1s
for
weight
loss,
leading
to
outrage
among
physicians
and
advocates,
though
they
are
still
covering
the
drug
for
patients
who
have
diabetes.
This
has
prompted
at
least
one
interviewed
for
this
story
to
say
comprehensive
coverage
in
terms
of
an
executive
order
from
the
White
House
may
be
what
is
necessary
to
make
sure
this
drug
is
available
to
those
who
need
it.
Starting
January
1,
Blue
Cross
Blue
Shield
of
Massachusetts
(BCBSMA)
will
no
longer
cover
GLP-1s
for
weight
loss
for
employers
with
fewer
than
100
employees.
Employers
with
more
than
100
employees
can
choose
to
cover
these
drugs
at
an
additional
cost.
BCBSMA’s
policy
applies
to
self-insured
and
fully-insured
employers.
“We’ve
made
this
decision
after
careful
consideration
and
to
be
responsive
to
customers
who’ve
expressed
to
us
that
they
are
no
longer
able
to
bear
the
burden
of
paying
for
these
high-priced
medications,”
said
Kelsey
Pearse,
a
spokesperson
for
BCBSMA.
Harvard
Pilgrim
Health
Care
—
an
insurer
in
Maine,
Massachusetts,
Rhode
Island
and
New
Hampshire
—
is
also
ending
GLP-1
coverage
for
weight
loss
for
most
commercial
plans
starting
January
1.
Large
fully-insured
employers
with
more
than
100
employees
can
opt
to
pay
to
continue
coverage.
Members
of
these
plans
will
be
required
to
complete
a
six-month
behavioral
modification
program
before
accessing
the
medication,
unless
they
are
already
using
it.
“Given
[the]
current
pipeline
of
pending
future
FDA
approvals
of
weight
loss
medications
for
alternative
indications
including
cardiovascular
conditions
and
other
comorbidities,
this
action
is
being
taken
to
ensure
affordability
of
coverage
for
all
our
members,”
a
Harvard
Pilgrim
Health
Care
spokesperson,
who
declined
to
be
named,
said.
In
other
words,
costs
are
only
expected
to
increase
with
these
additional
FDA
approvals
down
the
line.
While
no
definitive
number
is
available
to
show
how
many
insurance
companies
and
employers
are
dropping
coverage,
here
are
few
others
that
have
announced
ending
coverage
for
GLP-1s
for
obesity:
Blue
Cross
Blue
Shield
of
Michigan,
RWJBarnabas
Health
for
its
employees
and
Ascension
for
its
employees.
Medicare
also
does
not
cover
GLP-1s
for
weight
loss,
and
some
state
Medicaid
programs
are
rolling
back
coverage,
including
North
Carolina.
Former
President
Joe
Biden
proposed
a
rule
that
would
have
expanded
coverage
of
these
drugs
under
Medicare
and
Medicaid,
but
the
Trump
administration
chose
not
to
finalize
the
rule.
When
it
comes
to
self-insured
employers,
73%
are
covering
them
for
obesity,
while
99%
are
covering
them
for
diabetes,
according
to
a
recent
survey
from
the
Business
Group
on
Health.
To
manage
costs,
some
employers
are
implementing
cost-cutting
strategies
like
a
higher
body
mass
index
threshold
for
coverage.
When
asked
about
insurers
rolling
back
coverage
of
GLP-1s
for
weight
loss,
a
spokesperson
for
AHIP
said,
“obesity
is
a
complex,
chronic
condition
that
affects
millions
and
requires
individualized
care.
“While
GLP-1s
have
emerged
as
a
treatment
option
for
some
patients,
they
are
not
universally
appropriate
and
can
present
risks
or
challenges,”
said
Conner
Coles,
the
spokesperson.
“Health
plans
continue
to
assess
clinical
evidence
and
work
with
experts
to
support
coverage
policies
that
prioritize
safe,
effective,
and
clinically
appropriate
care
for
weight
loss.”
What
advocates
and
physicians
are
saying
While
insurers
may
be
ceasing
coverage
of
GLP-1s
for
obesity
due
to
cost
challenges,
one
obesity
medicine
physician
said
this
is
a
dangerous
game.
She
noted
that
while
obesity
often
contributes
to
numerous
other
health
conditions,
the
industry
typically
covers
treatments
for
those
conditions
—
but
not
obesity
itself.
“I
think
it’s
the
wrong
thing
to
do.
I
mean,
it’s
malpractice,
if
insurance
companies
could
be
held
to
malpractice
standards.
If
I
have
a
patient
with
obesity
today
and
I’m
seeing
them,
and
I
don’t
recommend
that
they
go
on
this
type
of
treatment,
I
think
you
could
consider
it
malpractice
today,
given
the
data
that
we
have
[on
how
well
these
drugs
work].
Especially
if
that
patient
had
multiple
other
issues
that
they
had
along
with
their
obesity,”
said
Dr.
Angela
Fitch,
co-founder
and
chief
medical
officer
of
metabolic
health
company
knownwell.
Fitch
is
also
the
former
president
of
the
Obesity
Medicine
Association.
Fitch
added
that
when
her
patients
don’t
have
coverage
for
GLP-1s,
she
has
to
advise
them
to
pay
cash
and
go
through
manufacturers’
direct-to-consumer
options
(Novo
Nordisk’s
NovoCare
or
Eli
Lilly’s
LillyDirect).
Or
she
has
to
switch
them
to
an
older
medication
that
requires
more
visits
and
potentially
more
side
effects.
A
healthcare
advocate
also
expressed
concern
over
insurers’
decisions
to
cease
coverage
of
GLP-1s
for
weight
loss.
Millicent
Gorham
is
the
CEO
of
the
Alliance
for
Women’s
Health
and
Prevention
and
leader
of
the
EveryBODY
Covered
campaign,
which
is
pushing
for
comprehensive
coverage
of
obesity
care.
She
noted
that
women
living
with
obesity
often
face
discrimination
in
the
workplace,
earn
less
money
than
their
colleagues
and
are
less
likely
to
be
promoted.
“To
see
insurers
roll
back
coverage
of
these
evidence-based
therapies
is
deeply
concerning,
as
these
decisions
reinforce
the
culture
of
stigmatization
for
women
living
with
obesity,
while
also
exacerbating
health
complications
associated
with
the
disease,”
she
said.
“We
as
a
society
need
to
break
from
the
misguided
belief
that
obesity
is
a
result
of
‘poor
lifestyle
choices.’
Obesity
management
medications
aren’t
‘vanity
drugs,’
they
are
critical
interventions
for
a
serious
chronic
disease.”
Gorham
added
that
if
insurers
care
about
cardiovascular
disease,
diabetes
and
cancer,
then
they
should
care
about
obesity
too.
Covering
these
medications
leads
to
fewer
emergency
room
visits,
fewer
surgeries
and
lower
rates
of
disability
and
absenteeism,
she
argued.
According
to
DoseSpot,
which
offers
software
to
providers
to
help
them
manage
prescription
ordering,
the
rollback
of
coverage
is
creating
a
lot
of
uncertainty
for
patients
and
providers.
That’s
why
the
company
is
using
its
platform
to
inform
providers
and
patients
of
what
financial
assistance
programs
there
are.
“We’re
bringing
more
power
into
the
patient’s
hands,
advocating
for
their
ability
to
see
pricing
of
medication
and
shop
pharmacies
that
might
have
the
medication
at
a
cheaper
price
or
more
convenient,
whether
it’s
mail
order
or
an
in-person
pharmacy
counter
experience,”
said
Josh
Weiner,
CEO
of
the
company.
What
manufacturers
are
saying
The
manufacturers
of
weight
loss
drugs
are
also
calling
out
insurance
companies
for
rolling
back
coverage
of
GLP-1s.
“We
are
disappointed
by
decisions
that
limit
access
as
it
is
contrary
to
actions
that
many
throughout
our
country
are
taking
to
expand
coverage
for
GLP-1s
for
weight
management,
recognizing
the
importance
of
these
medicines
for
people
living
with
obesity,”
said
Allison
Schneider,
director
of
media
relations
at
Novo
Nordisk.
“We
believe
that
comprehensive
coverage
through
government
and
commercial
insurance
plans
is
critical
to
providing
more
people
living
with
obesity
access
to
affordable
healthcare
and
treatment
options.”
Eli
Lilly,
which
manufactures
Zepbound
and
Mounjaro,
similarly
criticized
insurers’
actions.
A
spokesperson
who
declined
to
be
named
said
obesity
is
a
chronic
disease
and
should
have
comprehensive
coverage
like
other
diseases.
“Gaps
in
insurance
coverage
disrupt
effective
care
and
limit
access
to
safe,
evidence-based
obesity
management
medications,”
the
spokesperson
said.
“Lilly
believes
access
should
be
guided
by
clinical
evidence,
not
insurance
design.”
It’s
worth
noting,
however,
that
manufacturers
aren’t
necessarily
blameless
in
this
issue,
as
they’re
the
ones
pricing
the
medications.
Data
from
one
study
shows
that
Ozempic
can
be
manufactured
for
less
than
$5
a
month,
but
costs
about
$500
through
NovoCare.
What
needs
to
happen
While
there
were
efforts
to
expand
coverage
of
GLP-1s
under
Medicare
and
Medicaid
—
which
in
theory
would
encourage
more
employer-sponsored
coverage
—
this
wouldn’t
be
enough,
according
to
Fitch.
If
Medicare
were
to
start
covering
GLP-1s,
it
would
take
a
couple
of
years
for
that
to
take
effect,
and
then
a
few
more
years
for
commercial
insurers
to
follow
suit,
she
argued.
Instead,
there
needs
to
be
an
executive
order
from
the
White
House
that
makes
obesity
treatment
a
standard
benefit,
she
said.
“Our
health
system
is
not
designed
to
make
people
well
or
prevent
disease,”
she
declared.
“It’s
designed
to
treat
disease
after
it’s
already
happened.
But
we’re
in
a
new
era
now
where
we
can
actually
treat
the
root
cause
of
disease,
which
is
obesity,
and
prevent
all
these
other
diseases,
but
we
need
some
sort
of
urgent
public
health
action.”
So
while
Trump
could
be
the
hero,
that
doesn’t
mean
payers
should
wait
around
for
federal
action.
She
also
called
on
insurers
to
step
up.
“They
could
be
the
hero
right
now.
We
need
a
hero
in
obesity
…
because
we
have
revolutionary
treatment
in
our
hands
as
clinicians,
and
we
need
the
ability
to
get
it
out
to
people,”
Fitch
said.
Photo:
Jason
Dean,
Getty
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