Limited coverage of weight loss drugs may fuel health care disparities

December 20, 2023

3 minutes of reading


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Key takeaways:

  • Some health insurance companies limit coverage of pharmacological treatments for obesity.
  • Patients from underrepresented racial and ethnic groups are particularly vulnerable to barriers to coverage.

The AMA has adopted a policy supporting parity in insurance coverage for evidence-based weight loss drugs “without exclusions or additional exclusions,” the organization recently announced.

The new policy comes amid reports that some health insurance companies are imposing stricter coverage requirements for weight-loss drugs and some employers are suspending coverage altogether, according to a report by STATISTICS.


Some health insurance companies limit coverage of pharmacologic treatments for obesity, such as GLP-1 receptor agonists. Image source: Adobe Stock.

Weight loss drugs are also restricted in government programs. CMS is unable to cover them because of a 2003 law that established Medicare Part D prescription drug benefits.

Meanwhile, the out-of-pocket costs for these drugs are probably unsustainable for most patients. According to the Peterson-KFF Health System Tracker, the costs of weight loss drugs are:

  • $936 for Ozempic (semaglutide 1 mg, Novo Nordisk);
  • $936 for Rybelsus (semaglutide 7 or 14 mg, Novo Nordisk);
  • $1,349 for Wegovy (semaglutide 2.4 mg, Novo Nordisk); and
  • $1,023 for Mounjaro (tirzepatide 2.5 mg, Eli Lilly).

Experts said the high costs and lack of coverage could have far-reaching consequences, especially when it comes to addressing the obesity epidemic in the United States and ensuring health equity.

Health inequalities

Recent research suggests that semaglutide may cut in half the prevalence of obesity in the United States, where one in three adults is overweight, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

Low-income patients and certain racial and ethnic groups who are overweight or obese may be more affected by the lack of coverage than others, “especially since blacks and Hispanics experience obesity and related conditions more often than whites people,” he said Marcus Schabaker, MD, president and CEO of the Emergency Care Research Institute, a nonprofit health technology and safety organization.

“They only have access to processed foods that increase the risk of obesity and diabetes, and now they don’t even have access to effective treatment,” he told Healio.

Other health conditions that could be helped by weight loss drugs can be left untreated, “especially when it comes to secondary conditions such as diabetes, CVD, hypertension, as well as skeletal muscle problems such as hip or knee problems.” , Shabaker said.

“In an attempt to avoid covering these drugs in favor of short-term financial interests, insurance companies may be setting themselves up to pay for exponentially more expensive treatments down the road in a nation where nearly half of adults live with obesity,” he said. “So if we don’t cover them widely, it actually means higher costs in the end because then we have to pay for the treatment of these secondary diseases.”

Lower cost alternatives

Rebecca Andrick, DO, CNS, FOMA, bariatric medicine specialist, told Healio that for patients whose drugs like semaglutide become too expensive, “there are some lower-cost options that they should probably pursue and consider staying long-term to maintain that weight , which they lost,” she said.
that several drugs are approved for obesity, “and several of the combination drugs that we use can be prescribed generically, so sometimes the drug can be relatively inexpensive.”

Such combinations include naltrexone hydrochloride and bupropion hydrochloride (Contrave, Orexigen), “and people can get them from a mail-order pharmacy for $99 a month,” she said.

So, in addition to physical activity, “I would suggest trying to see if patients are good candidates for these other drugs, because the other thing we know about obesity is that it’s not just a chronic disease — it’s chronic and relapsing disease.” Andrik said.

References:

  • The AMA is pushing for coverage of obesity treatment because payers are not absorbing the cost. https://www.statnews.com/2023/11/13/weight-loss-drugs-wegovy-zepbound-ama-insurers/. Published November 13, 2023. Accessed December 13, 2023.
  • The AMA is pushing for parity in insurance coverage for emerging obesity treatment options. https://www.ama-assn.org/press-center/press-releases/ama-urges-insurance-coverage-parity-emerging-obesity-treatment-options. Published November 14, 2023. Accessed November 26, 2023.
  • Compendium of Social Security Laws. https://www.ssa.gov/OP_Home/ssact/title18/1860D-02.htm. Accessed December 12, 2023.
  • Employers cut off workers’ access to diet pills. https://www.wsj.com/health/healthcare/employers-cut-off-access-to-weight-loss-drugs-for-workers-cb277a44. Published August 2, 2023. Accessed December 12, 2023.
  • How do the prices of weight loss drugs in the US compare to prices in other countries? https://www.healthsystemtracker.org/brief/prices-of-drugs-for-weight-loss-in-the-us-and-peer-nations/. Published August 17, 2023. Accessed December 12, 2023.
  • Overweight and obesity statistics. https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity. Accessed December 12, 2023.

Sources/Disclosures

Shrinkage

source:

Helio interviews

Disclosures: Healio was unable to determine the relevant financial disclosures at the time of publication.

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