As insurance companies drop GLP-1 coverage, advocates seek obesity heroes
Obesity affects about two in five U.S. adults, and GLP-1 drugs have emerged as a promising solution, but their high price remains a significant obstacle.
For example, list prices for GLP-1 drugs range from $936 to $1,349 before insurance, rebates or other discounts.
Several insurance companies have decided to stop covering GLP-1 for weight loss because of the cost, drawing the ire of doctors and advocates, even though they are still covering the drug for people with diabetes.
That prompted at least one person interviewed for this story to suggest that sweeping coverage from the White House executive order may be necessary to ensure that people who need the drug can get it.
Beginning January 1, Blue Cross Blue Shield of Massachusetts (BCBSMA) will no longer cover GLP-1 for weight loss for employers with fewer than 100 employees. Employers with more than 100 employees can choose to pay an additional fee to cover these drugs. BCBSMA’s policies apply to self-insured and fully insured employers.
“We made this decision after careful consideration and in response to customers who told us they could no longer afford the cost of these high-priced medications,” said BCBSMA spokesperson Kelsey Pearse.
Harvard Pilgrim Health Care, located in Maine, Massachusetts, Rhode Island and New Hampshire, will also end GLP-1 weight loss coverage for most commercial plans starting Jan. 1. Fully insured large employers with more than 100 employees may choose to pay to continue coverage. Members of these programs will be required to complete a six-month behavior change program before receiving the medication, unless they are already using the medication.
“Whereas [the] Currently, FDA approval of a weight-loss drug for alternative indications such as cardiovascular disease and other comorbidities is pending, and this action is being taken to ensure affordable coverage for all of our members,” said a Harvard Pilgrim Health Care spokesperson who spoke on condition of anonymity.
In other words, with additional FDA approvals, costs are only expected to increase.
While there are no clear numbers showing how many insurance companies and employers are dropping coverage, the following companies have announced the end of coverage for GLP-1 obesity: Blue Cross Blue Shield of Michigan, RWJBarnabas Health, which provides services to its employees, and Ascension, which provides services to its employees.
Medicare also doesn't cover GLP-1 for weight loss, and some state Medicaid programs are scaling back coverage, including North Carolina. Former President Joe Biden proposed a rule that would expand coverage of these drugs under Medicare and Medicaid, but the Trump administration chose not to finalize the rule.
For self-insured employers, 73% offer coverage for obesity and 99% offer coverage for diabetes, according to a recent survey by the Health Business Group. To manage costs, some employers are implementing cost-cutting strategies, such as increasing the body mass index threshold for coverage.
When asked whether insurers would scale back GLP-1 weight loss coverage, an AHIP spokesperson said: “Obesity is a complex, chronic disease that affects millions of people and requires personalized care.
“While GLP-1s have become a treatment option for some patients, they are not universally available and may pose risks or challenges,” spokesman Conner Coles said. “Health plans continue to evaluate clinical evidence and work with experts to support coverage policies that prioritize safe, effective and clinically appropriate bariatric care.”
What advocates and doctors are saying
While insurance companies may stop covering obesity treatment GLP-1 Because of cost challenges, one obesity medicine physician says it's a dangerous game. She noted that while obesity often leads to many other health conditions, the industry often covers treatments for those conditions, but not obesity itself.
“I think it's the wrong thing to do. I mean, if insurance companies can adhere to malpractice standards, then that's medical malpractice. If I had an obese patient today and I was seeing them and I didn't recommend that they proceed with this type of treatment, I think you could consider that today based on the data that we have [on how well these drugs work]. “Especially if the patient has multiple other issues related to obesity,” said Dr. Angela Fitch, co-founder and chief medical officer of metabolic health company Knownwell, who is also the past president of the Obesity Medicine Society.
Fitch added that when her patients don't have GLP-1 insurance, she has to advise them to pay cash and choose the manufacturer's direct-to-consumer option (Novo Nordisk's NovoCare or Eli Lilly and Company's LillyDirect). Or she must switch to an older medication that requires more visits and may cause more side effects.
One health care advocate also expressed concern about the decision by insurance companies to stop covering GLP-1 for weight loss. Millicent Gorham is CEO of the Women's Health & Prevention Alliance and a leader in the EveryBODY Covered movement, which promotes universal coverage of obesity care. She noted that obese women often face discrimination in the workplace, earn less than their colleagues and are less likely to be promoted.
“It is deeply concerning to see insurance companies withdraw coverage for these evidence-based therapies, as these decisions reinforce a culture of stigma against obese women while also exacerbating the health complications associated with the disease,” she said. “As a society, we need to move away from the misconception that obesity is the result of 'poor lifestyle choices.'” Obesity management drugs are not 'vanity drugs,' they are critical interventions in the treatment of serious chronic diseases. “
Gorham added that if insurance companies care about cardiovascular disease, diabetes and cancer, then they should also care about obesity. She believes covering these drugs could reduce emergency room visits, surgeries, and rates of disability and absenteeism.
According to DoseSpot, which provides software to healthcare providers to help them manage prescription ordering, the rollback of coverage has created a lot of uncertainty for patients and healthcare providers. That’s why the company uses its platform to inform providers and patients about what financial assistance programs are available.
“We're empowering patients by advocating for their ability to see drug pricing and purchase their medications at pharmacies where they may be able to get them at a cheaper or more convenient price, whether that's mail order or an in-person pharmacy counter experience,” said Josh Weiner, the company's CEO.
What the manufacturer says
Diet pill manufacturers have also called on insurance companies to reduce GLP-1 coverage.
“We are disappointed with the decision to limit access because it runs counter to the actions many across our country have taken to expand GLP-1 weight management coverage and recognize the importance of these drugs for patients with obesity,” said Allison Schneider, director of media relations at Novo Nordisk. “We believe that comprehensive coverage by government and commercial insurance plans is critical to providing more patients with obesity with affordable healthcare and treatment options.”
Eli Lilly, the maker of Zepbound and Mounjaro, also criticized the insurer's approach action.
A spokesman, who asked not to be named, said obesity was a chronic condition and should be comprehensively covered like other conditions.
“Gaps in insurance coverage disrupt effective care and limit access to safe, evidence-based obesity management medicines,” the spokesperson said. “Eli Lilly believes access should be guided by clinical evidence, not insurance design.”
It’s worth noting, however, that manufacturers are not necessarily blameless on this issue, since they are the ones who set the price of the drug. data from a study Ozempic costs less than $5 a month to make, but costs about $500 through NovoCare.
what needs to happen
Fitch said that while there are efforts to expand GLP-1 coverage under Medicare and Medicaid (which would theoretically encourage more employer-sponsored coverage), this is not enough. She believes that if Medicare starts covering GLP-1, it will take several years for it to take effect, and then several more for commercial insurance companies to follow suit. Instead, she said, the White House needs to issue an executive order making obesity treatment a standard benefit.
“Our health system is not designed to rehabilitate people or prevent disease,” she declared. “It's designed to treat disease after it occurs. But we're now in a new era where we can actually treat the root cause of disease, which is obesity, and prevent all these other diseases, but we need to take some kind of urgent public health action.”
So while Trump may be a hero, That doesn’t mean payers should wait for federal action. She also called on insurance companies to take action.
“They could be heroes now. We need heroes in obesity … because as clinicians, we have a revolutionary treatment in our hands, and we need to have the ability to get it to people,” Fitch said.
Photo: Jason Dean, Getty Images
