As demand for GLP-1s such as Ozempic and Wegovy continues to surge, payers and self-insured employers are dropping coverage for the weight loss medications left and right.
According to new data from weight management platform Found, 69 percent of patients do not have insurance coverage as of June for GLP-1s for anti-obesity or diabetes, a 50 percent decline in coverage since December 2022.
"Demand has been accelerated through things like TikTok and advertisements around these medications, so a lot more prescriptions are being written," Found CEO Sarah Jones Simmer told Becker's. "In reaction, payers are putting more pressure on their PBMs to introduce prior authorization or create more hurdles to getting access or just dropping them from the formulary entirely."
St. Louis-based Ascension dropped coverage for weight loss drugs from its employee health plan in July, and the University of Texas System in Austin is ending coverage under its employee and retiree health plans in September, citing high costs and low adherence rates.
GLP-1s come with a steep price tag, costing upward of $10,000 per year without insurance. Private insurers often do not cover GLP-1 drugs for weight loss only, though they have been more likely to cover the drugs when they are prescribed to treat diabetes. Ozempic, Trulicity, Victoza and Mounjaro are FDA approved to treat Type 2 diabetes, and Wegovy and Saxenda are approved for weight loss.
But according to Found's latest data, GLP-1 insurance coverage for patients with diabetes has fallen dramatically, decreasing from 27 percent of diabetes patients covered in December to 12 percent in June.
"That's concerning on a lot of levels," Ms. Jones Simmer said. Found's chief medical officer, Rekha Kumar, MD, added that the decreasing coverage for diabetic patients is leaving many physicians feeling as if they have little say when it comes to prescribing GLP-1s.
"These are incredibly effective medications, and they should be part of a broad toolkit of providing access to comprehensive obesity care," Dr. Kumar said. "When we have to limit our options because of insurance coverage, that may limit the potential for life-changing care for someone."
For patients seeking a prescription for weight loss and to have it be covered by insurance, some physicians have turned to prescribing Ozempic off label. In response, health insurers have cracked down on off-label prescriptions, with some warning clinicians about prescribing Ozempic to non-diabetic patients and even threatening to report providers to law enforcement agencies and medical boards.
"There are folks out there that are operating like vending machines for Ozempic. That's not how medicine should be practiced," Ms. Jones Simmer said. "This shouldn't be black or white, that you either give it to everyone who meets the FDA criteria or you give it to no one."
"For medications this expensive, we want to know it will work for the people we're giving it to," Dr. Kumar added. "You should select patients that are best for the treatment, which requires a comprehensive evaluation, an understanding of the patient and a full lifestyle plan."