Supplies of popular obesity medications are on the rise, but obtaining them remains a challenge for many patients. Employers and insurers are increasingly limiting coverage for medications like Wegovy and Zepbound, and crucial government programs such as Medicare do not include these drugs in their obesity treatment plans. While certain large employers are offering coverage, there are no guarantees that this commitment will persist.
The high cost of treatments, sometimes exceeding hundreds of dollars each month even after discounts, makes it difficult for individuals to afford these drugs without insurance. As a result, the significant weight loss that patients seek is often dependent on the type of coverage they possess and its longevity.
Coverage challenges are not unusual in the U.S. healthcare system, but the issue is amplified with obesity treatments. This is because a large segment of the population may qualify to receive them, and ongoing use of these medications is crucial for maintaining weight loss. Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, emphasized that many individuals are currently unable to access the medications they need.
The variability in insurance coverage largely hinges on who is paying the bills. For instance, Paul Mack, a resident of Redwood City, California, lost around 70 pounds after beginning treatment with Wegovy. He experienced fewer cravings for food and improved his health sufficiently to undergo a heart procedure. Initially, his treatment was covered by California’s Medicaid program, Medi-Cal, but when he received a raise and lost eligibility for the program, he went without coverage for several months last summer, subsequently regaining two sizes.
Despite the introduction of Zepbound to the market over a year ago to compete with Wegovy, coverage for these medications still remains inconsistent. According to a benefits consultant, nearly 44% of U.S. companies with 500 or more employees provided coverage for obesity medications last year, with coverage more prevalent among larger employers. Additionally, various government-funded Medicaid programs for low-income individuals include obesity treatment; however, very few insurers cover these drugs within individual insurance marketplaces, often implementing restrictions like prior authorization.
The absence of Medicare coverage is a significant concern, especially for retirees transitioning from employer-sponsored plans to Medicare. Dr. Katherine Saunders, an obesity specialist, noted that patients often express anxiety about losing access to medications when they move to Medicare, prompting discussions about backup plans long before the transition.
Concerns about costs and the potential return on investment are significant factors for insurers. In the Philadelphia area, Independence Blue Cross recently withdrew weight loss medication coverage for certain customers, citing worries over premium increases. Similarly, North Carolina and West Virginia ended similar state coverage programs due to cost factors, making it uncertain how long current employers will maintain coverage for obesity drugs now that supply has stabilized.
While drug manufacturers argue that these medications can ultimately save money by preventing severe health complications, healthcare experts caution that coverage benefits may not always reach the employer or insurer due to job or insurance changes. The future of widespread coverage for obesity treatments remains unclear, despite polling indicating public support for including these drugs under Medicaid and Medicare.
Eli Lilly, the manufacturer behind Zepbound, has observed a gradual increase in coverage and remains hopeful for continued expansion. Former President Biden’s administration had proposed regulations that would enable broader coverage under Medicare and Medicaid; however, its progress appears uncertain under the current political climate. Legislation advocating for Medicare coverage has been in Congress for years without a scheduled vote.
With several new obesity treatments being tested by drugmakers, the emergence of more competitive options could lead to reduced prices and wider coverage. Nevertheless, the existing inconsistencies in coverage create complications for treatment plans.
Dr. Amy Rothberg expressed reservations about prescribing these medications when coverage is unreliable, as studies indicate that patients often regain weight once they discontinue medication. Dr. Lydia Alexander, president of the Obesity Medicine Association, noted that some insurers require patients to implement lifestyle changes before they can access weight-loss medications, while others stipulate that coverage only begins for patients with severe obesity, defined by a body mass index of 40 or higher. She asserted that although obesity is recognized as a disease, the approach to treatment does not reflect its classification.
