Obesity medications like Ozempic may not be covered by health insurance

The demand for anti-obesity drugs is expected to grow exponentially as shortages decrease and new drugs enter the market.

But the drugs cost $1,000 a month or more and must be taken indefinitely.

With more than 40% of Americans overweight enough to qualify for these drugs — and most no longer eligible for insurance to pay for them — how much prevention can individuals and the country pay for?

Dr. Marcus Schabaker, president and CEO of ECRI, a nonprofit organization that works to improve health care, said it’s good that the pharmaceutical industry continues to look for drugs to treat obesity. But Schabaker said, “It just doesn’t help if it’s out of reach for the majority of patients who need it.”

Health technology company Komodo Health estimates that more than 2 million prescriptions were written last year for Wegovy, the brand name of Novo Nordisk’s semaglutide drug, and for Eli Lilly’s tirzepatide, a diabetes drug that has not yet been approved for weight loss

These drugs are expected to become more widely available this year, and demand for prescriptions is expected to increase significantly.

Semaglutide has been shown to help reduce excess weight by about 15%, and tirzepatide by 20%, an unprecedented amount for drugs. They are also expected to reduce health effects and, as a result, medical costs.

“Obesity is a huge medical problem in the United States, and here are drugs that actually work,” said Dr. David Rhind, chief medical officer of the Institute for Clinical and Economic Review, which evaluates the value of drugs. “We’ve been waiting for drugs that do something like this for a really long time.”

Not everyone who weighs more than what is considered healthy will want or benefit from these drugs. And weight loss from medication, while impressive, will not by itself make heavy people thin. But until recently, there were no drugs to help people lose weight of this type.

Wegovy shortages caused by supply chain disruptions have kept demand tight since it won approval in June 2021. Now Novo Nordisk says it has fixed those problems, and some doctors say their patients can get the drug.

But Wegovy’s list price is $1,349.02 per month, or more than $16,000 per year, at the full anti-obesity dose. The same drug, sold under the brand name Ozempic, is sold at a lower price in a lower dose to treat diabetes.

This year, federal regulators will consider approving tirzepatide, which appears to help people lose even more weight. Since drugmaker Eli Lilly received approval in May for the drug as a diabetes treatment, it has been selling tirzepatide for $1,000 a month under the brand name Mounjaro. Similar drugs are likely to be approved in the coming years.

These new anti-obesity drugs, such as those that treat high blood pressure and cholesterol, must be taken indefinitely. So once people start taking them, they will have to continue or risk the pounds coming back.

The global market for anti-obesity drugs is expected to grow 25% over the next five years, driven largely by demand in North America, according to Medi-Tech Insights, a business research firm.

Treating the health consequences of obesity costs the US health care system $170 billion annually, according to ECRI.

In the past, it made some sense for insurance companies not to cover obesity drugs, Rind said. That’s because many drugs promote weight loss of only about 5%, the lower limit of what will change someone’s health.

And a number of approved weight loss drugs were pulled from the market when they were found to be unsafe. In 2022, the Federal Food and Drug Administration withdrew approval for the weight-loss drug lorcaserin, sold as Belviq, because of an increased risk of cancer among people who took the drug long-term. One of the drugs in the combination, known as fen-phen — a combination of fenfluramine and phentermine — was recalled in 1997 because of damage to heart valves.

But now that effective drugs are available, lack of coverage makes no medical sense.

“No one would ask someone who has hypertension to exercise and not give them a beta-blocker or any other approved medication,” Schabaker said. “If those Americans who are eligible for treatment were covered by insurance plans or Medicare/Medicaid, it would help reduce health care costs for secondary diseases, such as hypertension, diabetes and musculoskeletal disorders.”

If incomplete health insurance coverage for anti-obesity drugs continues, it is likely to exacerbate economic and ethnic disparities, especially among children, said health economist John Cowley of Cornell University.

“Teens and young adults whose parents have health insurance will get coverage; no others,” said Cowley.

Now the burden of paying for weight loss procedures usually falls on the patient. Most health plans do not cover the cost of weight loss drugs. Neither are government programs like Medicare.

Novo Nordisk, in a recent presentation to investors, said 40 million American adults have at least some insurance coverage on Wegovy. Approximately 108 million adults in the US meet the definition of obesity.

The lack of coverage at least partially explains why only about 2 percent of obese Americans have ever been treated with either weight-loss drugs or surgery.

Once more weight-loss drugs hit the market, there will be some competition and prices may come down, said Rhind, who is an internist at Beth Israel Deaconess Medical Center in Boston. However, if a drug looks better and becomes what everyone wants, “it’s going to continue to cost a lot,” he said.

Rhind’s organization recommended that Medicare begin paying for anti-obesity drugs.

Commercial insurers should also cover the drugs, he said. It looks like they will save money if people lose weight, but those cost offsets will happen years into the future, by which time a person may have switched coverage plans.

And patent protections will keep cheap generics off the market for at least two decades.

Read more at USA today.

Leave a Comment

Your email address will not be published. Required fields are marked *