Payers are mostly denying coverage for weight-loss drugs, but a loophole exists

Getting payers to cover drugs meant to treat obesity can be difficult, but some physicians say there are workarounds, according to The New York Times.

One example is Maya Cohen, who visited Caroline Apovian, MD, an obesity specialist at Brigham and Women's Hospital in Boston. Dr. Apovian prescribed her a new weight loss drug called Saxenda. The out-of-pocket pharmacy cost for Saxenda was $1,500 a month, and Ms. Cohen's health plan would not cover it, classifying the drug as "vanity."

Dr. Apovian told the Times she was not surprised by the denial and said it was a common response from commercial payers and a universal response from Medicare.

Saxenda's Danish manufacturer, Novo Nordisk, and patient advocacy groups have been lobbying payers and Congress to cover more weight-loss drugs on commercial plans and Medicare, but to no avail.

Scott Kahan, MD, director of the National Center for Weight and Wellness, told the Times that even if a payer will cover the drugs, most physicians and patients don't know they exist as good options or believe they haven't been studied enough. 

But some physicians have found a loophole to prescribe Novo Nordisk drugs to obese patients whose health plans won't cover weight-loss drugs, according to the Times.

Novo Nordisk sells semaglutide, a drug meant for treating diabetes and obesity. For diabetes, the brand name is Ozempic, which costs $892 every four weeks and is typically covered by payers for diabetic patients.

Novo Nordisk also sells two weight loss drugs that are of the same class in two doses. Liraglutide is sold as Saxenda and semaglutide is sold at a higher and more effective dose as Wegovy. The list price for both is around $1,350 a month, which means the same drug is 51 percent more expensive if it is used to treat obesity over diabetes. Most payers do not cover Saxenda or Wegovy because they are weight-loss drugs.

"It's unbelievable," Dr. Apovian told the Times.

Dr. Apovian finds it inequitable to charge patients more for the same drug because of their weight. She said she gets excited when her obese patients have diabetes or high blood sugar levels because then the weight-loss drugs are covered.

Her patient, Ms. Cohen, had high blood sugar levels and her insurance plan covered Ozempic, which she now receives for a $70 a month copay.

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