Availability of sought-after obesity medications like Wegovy and Zepbound is improving, but that doesn’t necessarily mean they’re easier to obtain.
Many employers and insurers, including a major government program, Medicare, are pulling back the coverage. While some major employers have started to provide coverage, such commitments may not be permanent.
Given the prices of these treatments, which can escalate to hundreds of dollars monthly even with discounts, many individuals find these drugs financially out of reach without coverage. This means that for those seeking transformative weight loss, access is largely contingent on the coverage available and its duration.
Navigating insurance coverage is often complex in the U.S. healthcare system, but the challenge is amplified in the case of obesity medications because a substantial portion of the population could be eligible to take them, and continued use is necessary to maintain weight loss.
“There are a lot of people right now who want access to the medication and can’t get it,” notes Katherine Hempstead, a senior policy adviser with the Robert Wood Johnson Foundation.
The extent of coverage differs based on who foots the bill.
For instance, Paul Mack from Redwood City, California, experienced a 70-pound weight loss after starting Wegovy. The aid allowed him to overcome his constant preoccupation with food and undergo a heart procedure.
Initially, his treatment was funded through California’s Medicaid program, Medi-Cal. However, following a pay raise, Mack disqualified from Medi-Cal and faced months of ineligibility for the drug last summer.
In that period, he regained two pants sizes. “I couldn’t control the eating,” he shared. “All the noise came back.”
More than a year post Zepbound’s market entry, challenging Wegovy, the coverage landscape remains inconsistent.
A report from the benefits consultant Mercer reveals that 44% of U.S. companies with 500 or more employees provided obesity drug coverage last year, with greater prevalence among larger organizations.
Moreover, several government-sponsored Medicaid programs for low-income individuals include obesity treatments in their coverage.
Nonetheless, few insurers offer these drugs through individual insurance marketplaces, and some impose limitations such as prior authorization requests.
The absence of Medicare coverage poses further concern, particularly for individuals swapping employer-sponsored plans for the government-funded program upon retirement.
“Patients come to us terrified about switching to Medicare and losing coverage,” mentions Dr. Katherine Saunders, an obesity specialist with Weill Cornell Medicine and co-founder of the obesity treatment company FlyteHealth. “We start talking about backup plans a year before they transition.”
Cost considerations and uncertain benefits remain pivotal concerns for payers.
For instance, Independence Blue Cross in the Philadelphia area ceased covering weight loss drugs for some customers this year, citing potential premium increases it would impose if continued.
Similarly, cost influenced decisions from officials in West Virginia and North Carolina to discontinue comparable programs for state employees.
Given the restored supply of these drugs, researchers like Vanderbilt University’s Stacie Dusetzina are curious about the longevity of employer-provided coverage.
“That’s probably going to spike spending,” remarks Dusetzina, a health policy professor delving into drug costs.
Drugmakers highlight the economic benefits these drugs envisage by enhancing patient health and preventing future serious conditions like heart attacks or strokes.
However, health care experts caution that these anticipated gains aren’t guaranteed for those covering the drugs, given the possibility of employees switching jobs or insurers.
Achieving consistent coverage remains an elusive goal.
Despite polls indicating favorable public opinion towards Medicaid and Medicare covering these costs, a straightforward roadmap to universal coverage isn’t evident.
Eli Lilly, maker of Zepbound, reports expanding coverage and maintains optimism for continued growth.
A proposal by the former President Biden’s administration could potentially enable Medicare and broader Medicaid coverage, yet its future is unclear under President Donald Trump’s administration.
A long-standing bill advocating for Medicare coverage resists progression through Congress, lacking a scheduled vote.
Meanwhile, drugmakers are testing several prospective obesity treatments that could stimulate price reductions and broaden coverage.
Dr. Amy Rothberg points out how inconsistent coverage challenges treatment plans.
“We know from the studies that people go off these medications, they regain their weight,” says Rothberg, head of the University of Michigan’s weight-management program. “I don’t want to do harm.”
Requisite lifestyle modifications, such as diet and exercise adjustments, often precede a weight-loss medication approval from insurers.
“We’re saying that obesity is a disease, but we’re not treating it like a disease,” says Dr. Lydia Alexander, president of the Obesity Medicine Association. She particularly observes the barrier of a requisite body mass index of 40 or more, signifying severe obesity before coverage initiation.
