The increasing prevalence of weight loss medications, particularly GLP-1 receptor agonists, has led to greater patient interest in understanding their costs and insurance coverage. These newer medications, initially developed for diabetes treatment and sometimes prescribed off-label for weight loss, have prompted manufacturers to rebrand and seek FDA approval specifically for obesity treatment. While some older weight loss medications have affordable generic versions, the newer drugs often carry a significant price tag, making coverage a crucial factor for many patients.
The High Cost of Newer Weight Loss Medications
Newer weight loss medications can be expensive. As of October 2022, a month's supply of Wegovy (semaglutide) cost around $1,300. Given that drugs like tirzepatide and semaglutide are intended for long-term use, the financial commitment is substantial.
Payer Coverage Policies: A Complex Landscape
Many insurers and employers view weight loss as a cosmetic concern rather than a medical necessity. Consequently, payers often do not cover weight loss medications, including commercial insurers, Medicare, and Medicaid. Medicare is legally prohibited from covering these medications. However, coverage can vary depending on the specific plan and payer. Some plans may cover certain weight loss medications, sometimes requiring prior authorization, while others offer no coverage.
The Medicare Exclusion: A Historical Perspective
Medicare's exclusion of weight loss medication coverage stems from safety concerns arising from the fen-phen experience in the 1990s. Fen-phen, a combination of fenfluramine and phentermine, caused rapid weight loss but was later linked to heart valve damage, leading to its removal from the market in 1997. This event significantly influenced the creation of Medicare Part D in 2003, which aimed to manage prescription drug costs under the Medicare Modernization Act.
Arguments for Coverage: Obesity as a Medical Condition
Despite coverage limitations, there are compelling arguments for including weight loss medications in insurance plans. In 2010, the Affordable Care Act expanded coverage for interventions like bariatric surgery to treat obesity. The American Medical Association officially recognized obesity as a disease a decade ago, a position shared by the Obesity Medicine Association (OMA). This perspective supports the view that weight loss drugs are a legitimate medical treatment.
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Furthermore, obesity is linked to cardiovascular and other related diseases. Studies on Wegovy have demonstrated cardiovascular benefits, and research indicates that treating obesity can help prevent diabetes and heart disease. Preventative approaches could potentially save payers money in the long run.
Legislative Efforts: The Treat and Reduce Obesity Act
Congress has been advocating for Medicare to cover weight loss medications, exemplified by the Treat and Reduce Obesity Act of 2023 (H.R. 4818 and S. 2407). The Congressional Budget Office (CBO) is assessing the potential for preventive medical care, including obesity treatment, to reduce costs.
The CBO acknowledges that the growing market for anti-obesity medications could significantly impact healthcare spending and the federal budget. While the Treat and Reduce Obesity Act might increase costs for these medications due to increased usage, it could also reduce federal costs for obesity-related health issues.
Eligibility Criteria for Weight Loss Medications
Eligibility for weight loss medications varies. For instance, Wegovy is approved for individuals with a BMI of 30 or greater or a BMI of 27 or greater with comorbidities like high blood pressure, diabetes, or high cholesterol. Zepbound is approved for adults with a BMI of 30 or greater. Age is also a consideration, with Zepbound currently approved only for adults but under study for adolescents. Some GLP-1 agonists, as well as other medications like orlistat and Qsymia, are approved for individuals aged 12 and older, while phentermine is approved for adolescents 16 and older. Specific options may be available for children with rare genetic diseases causing obesity.
Increasing Interest and Usage of Weight Loss Medications
There has been a noticeable increase in patient interest in weight loss medications. Semaglutide, including Ozempic and Wegovy, was a major focus of Trilliant Health's 2023 "Trends Shaping the Health Economy." Sales of semaglutide totaled $10.7 billion in 2021, with prescriptions increasing by 300% from 2020 to 2022, encompassing both diabetes and weight loss treatments.
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The CBO reported that sales of anti-obesity medications reached $1.1 billion in the second quarter of 2023, a 65% increase over the previous quarter. Celebrity endorsements have also contributed to increased public interest.
Discontinuation Rates and Potential Side Effects
Despite the initial enthusiasm, many individuals discontinue weight loss medications within a year. A July 2023 report indicated that around two-thirds of patients stopped taking the medications within a year, even when insurance covered the costs. Reasons for discontinuation include reaching a weight loss plateau, intolerance to side effects, or medication shortages.
Potential side effects of GLP-1 agonists include nausea, vomiting, diarrhea, dizziness, mild tachycardia, and headaches. Concerns exist regarding heightened risks of anesthesia complications for individuals using these drugs. Furthermore, discontinuing the medications can lead to weight regain. A study in Diabetes, Obesity & Metabolism found that individuals who stopped semaglutide regained some weight after initially losing an average of 17.3% of their body weight. Improvements in blood pressure were also reversed, although blood sugar and cholesterol levels remained improved.
Helping Patients Navigate Weight Loss Medication Options
Given the high costs, limited insurance coverage, and potential for weight regain upon discontinuation, guiding patients who want to take weight loss medications is crucial. Before initiating a GLP-1 agonist, checking the FDA Drug Shortages List is advisable to ensure a reliable supply. Cost considerations are also essential.
For patients whose insurance does not cover weight loss medications, comparison shopping can be beneficial. GoodRx allows patients to compare prices across pharmacies and find coupons. Similar services may be available at the state level. Many drug manufacturers offer patient assistance programs with discounted pricing.
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Understanding Prescription Drug Lists (Formularies)
A Prescription Drug List (PDL), also known as a formulary, is a list of commonly used medications organized into cost levels called tiers. Employers or health plans determine these costs. Checking the member account or contacting the number on the health plan ID card provides specific information about pharmacy benefits and the PDL.
Health plans are required to cover certain preventive care medications at no cost to the patient under the Affordable Care Act. Preventive medications may be covered before meeting the deductible, depending on the plan.
TRICARE Coverage for Weight Loss Medications
TRICARE beneficiaries considering weight loss drugs like Zepbound or Wegovy should understand the differences between TRICARE plans and coverage. Regulatory controls on weight loss medication coverage are being implemented by the Defense Health Agency, effective August 31, 2025.
TRICARE Prime and TRICARE Select may still cover these medications under certain circumstances. An approved prior authorization for weight loss drugs may no longer be valid. If a weight loss drug is not covered, consulting with a provider about alternative options is recommended.
TRICARE covers weight loss medications for specific beneficiary groups, based on diagnosis, medical necessity, and the TRICARE plan. Trulicity, Ozempic, Mounjaro, and Victoza are covered for treating type 2 diabetes. The TRICARE Formulary Search Tool can be used to check drug coverage and costs. GLP-1s for diabetes treatment continue to be covered for all patients with a diabetes diagnosis when medically necessary and with prior authorization.
Additional Resources and Cost-Saving Measures
Several resources and strategies can help reduce prescription costs. Express Scripts accounts provide easy access to prescription drug information. Programs like the Chronic Illness Support Program (CISP) offer additional benefits and coverage for individuals with conditions like asthma, coronary artery disease, COPD, diabetes, and hypertension.
Care managers can help coordinate care. If a medication is not on the plan's formulary, discussing alternatives with the provider or requesting a formulary exception may be options. Community Health Options provides a Medication Prior Authorization Form for this purpose and offers appeal and external review processes for denied requests.
Personal Experiences and Patient Stories
Personal experiences highlight the challenges and successes of weight management. One individual shared their journey of weight loss and the difficulties of maintaining it, emphasizing the importance of portion control. The unavailability of Saxenda led to the exploration of alternative medications and ultimately significant weight loss.