1% of ACA health plans cover GLP-1s for weight loss: KFF

The majority of ACA marketplace plans cover GLP-1 drugs approved for diabetes, though fewer than 1% of plan formularies include drugs solely approved to treat obesity, a new analysis from KFF shows. 

The weight loss medication coverage landscape is complex. Numerous insurers, health systems, self-funded employers and state health plans have ended or restricted coverage for weight loss drugs, which can cost upward of $10,000 a year. Most recently, Blue Cross Blue Shield of Michigan moved to drop coverage of GLP-1 drugs for weight loss in fully insured, large group commercial plans. 

Novo Nordisk, the manufacturer of Ozempic and Wegovy, has denounced lawmakers' heightened scrutiny on list prices of the medications, calling it "misplaced and unfair." The drugmaker said it spent more than $10 billion to develop the drugs. Ozempic is approved to treat Type 2 diabetes and can be prescribed off-label for weight loss. Wegovy is approved for weight loss.

Below are three coverage trends from KFF's June 12 analysis, which is based on publicly available formularies for plans on the ACA marketplace in 2024: 

  • Plans typically cover GLP-1s approved to treat diabetes: Eighty-two percent of ACA plans include Ozempic in their formularies, 76% include Rybelsus, 60% include Victoza and 51% include Mounjaro. 

  • Fewer than 1% cover drugs approved for obesity, including Wegovy.

  • ACA plans that cover GLP-1s often employ utilization management strategies, including prior authorization (86% for Ozemic) and quantity limits (96% for Ozempic). Step therapy was a less commonly used strategy. All plans covering the drugs for weight loss require prior authorization. 

Other context to know: 

  • Medicare does not cover GLP-1s when solely used for weight loss. In March — after Wegovy was approved to reduce the risk of heart attacks and strokes — CMS issued guidance stating Medicare Part D drug benefit plans may cover anti-obesity medications if they are approved for additional health benefits and used for those conditions. Many Part D plans already cover GLP-1s including Ozempic for Type 2 diabetes.

  • From 2018 to 2022, total Medicare Part D spending on three GLP-1s used to treat diabetes surged from $57 million to $5.7 billion.

  • Under the current pricing structure, weight loss drugs would cost the U.S. healthcare system $411 billion per year if half of Americans with obesity used them. If half of all Medicare and Medicaid enrollees with obesity did so, the cost would be $155 billion annually, according to estimates in a May 15 report from Sen. Bernie Sanders' office.

  • One in 4 patients using GLP-1 agonists report their insurance covered the full cost, while 57% said at least part of the cost was covered by their insurance, a recent KFF survey shows. At the same time, 54% of adults taking the drugs reported difficulty paying for them — a proportion that includes those who are insured. 

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