With the increasing popularity of weight loss medications and growing patient inquiries about their costs, understanding insurance coverage, particularly from providers like MVP, is crucial. This article delves into the coverage of weight loss drugs, focusing on factors influencing coverage decisions and providing guidance for patients seeking these medications.
The Rising Demand and Cost of Weight Loss Medications
The market has seen a surge in newer weight loss medications, especially GLP-1 receptor agonists. Drugs like tirzepatide and semaglutide, initially diabetes treatments, have gained FDA approval for obesity treatment, sometimes through rebranding. While older medications may have affordable generics, newer drugs can be expensive. For instance, a month's supply of Wegovy (semaglutide) cost around $1,300 as of October 2022. Given that these medications are often intended for long-term use, the financial commitment is significant.
In 2021, sales of semaglutide (including Ozempic and Wegovy) totaled $10.7 billion, and prescriptions for these medications increased by 300% from 2020 to 2022. In the second quarter of 2023 alone, sales of anti-obesity medications reached $1.1 billion, a 65 percent increase from the previous quarter.
Insurance Coverage: A Complex Landscape
Many insurers, including commercial insurers, Medicare, and Medicaid, often do not cover weight loss medications, viewing weight loss as a cosmetic rather than a medical necessity. Medicare is legally prohibited from covering these drugs, a consequence of safety concerns stemming from the fen-phen controversy in the 1990s.
However, coverage can vary significantly from plan to plan. Some plans from certain payers may cover specific weight loss medications, sometimes requiring prior authorization.
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Medicare's Stance
Medicare's restriction on covering weight loss drugs dates back to the Medicare Modernization Act of 2003, which launched Medicare Part D. This legislation was influenced by the adverse effects of fen-phen, a combination drug that caused heart valve damage and was withdrawn from the market in 1997.
Arguments for Coverage
Despite coverage limitations, there are compelling arguments for including weight loss medications in insurance plans. The American Medical Association officially recognized obesity as a disease a decade ago, a position shared by the Obesity Medicine Association (OMA), thus framing weight loss drugs as a legitimate medical treatment. Additionally, obesity is linked to cardiovascular and other related diseases. Data on drugs like Wegovy indicates cardiovascular benefits, and research suggests that treating obesity can prevent diabetes and heart disease, potentially saving payers money in the long run.
Legislative Efforts
Congress has been advocating for Medicare to cover weight loss medications, demonstrated 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.
Eligibility for Weight Loss Medications
Eligibility for weight loss medications depends on factors like Body Mass Index (BMI) and age. For example, 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. While Zepbound is currently only approved for adults, studies are underway for adolescent use. Some GLP-1 agonists, along with medications like orlistat and Qsymia, are approved for individuals aged 12 and older, while phentermine is approved for those 16 and older.
MVP's Medicare Advantage Plans
MVP offers Medicare Advantage plans to residents of specific regions in northern New York. These plans include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) options, prescription drug coverage (Part D), and extra benefits like fitness programs, hearing aids, and telehealth services. MVP plans operate within a network of over 60,000 healthcare professionals.
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Types of MVP Medicare Advantage Plans
HMO-POS Plans: MVP offers HMO plans as HMO Point-of-Service (HMO-POS) plans, providing more flexibility than traditional HMOs. These plans do not require referrals from a primary care physician (PCP), and members can see out-of-network professionals at a higher copay.
PPO Plans: MVP also offers PPO plans, which, like HMO-POS plans, allow members to see out-of-network providers, albeit at a higher cost.
Coverage and Extra Benefits
MVP Medicare Advantage plans include Part D prescription drug coverage, which can sometimes be opted out of. These plans offer additional services such as:
- Emergency out-of-network care
- Emergency care when traveling abroad
- Free preventive care, including screenings and vaccinations
- Free membership to SilverSneakers
- Free meal delivery after hospital stays
- Hearing aid discounts
- Vision benefits with EyeMed and glasses allowance
- Rewards gift cards for completing health and wellness activities
- $0 copays for telehealth visits
- Free health management services
- Discounts on over-the-counter medicines
- Free transportation to medical appointments with some plans
- Optional extra dental coverage
Cost of MVP Plans
The cost of MVP plans varies based on the county and the chosen plan. The monthly premium is in addition to the standard Part B premium.
Ozempic Coverage and Savings
Ozempic, while not FDA-approved for weight loss, is often prescribed off-label. Most commercial prescription plans cover Ozempic for treating type 2 diabetes, but coverage for weight loss is less common. The cost for Ozempic can range from $0 to $1029 per month.
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Savings Options
- Novo Nordisk Savings Card: For eligible individuals with commercial insurance, the Novo Nordisk Savings Card can offer savings of up to $150 for a 1-month prescription, $300 for a 2-month prescription, and $450 for a 3-month prescription.
- Patient Financial Assistance: Novo Nordisk may offer patient financial assistance based on income eligibility for those without insurance.
Medicaid Coverage
Most state Medicaid programs cover GLP-1 agonists like Ozempic for type 2 diabetes. However, coverage for weight-loss drugs may vary by state, with some states having special requirements before coverage begins.
Strategies for Patients
Given the high costs, potential lack of insurance coverage, and the risk of weight regain after stopping medication, here are some strategies for patients considering weight loss drugs:
- Check Drug Availability: Before starting a GLP-1 agonist, check the FDA Drug Shortages List to ensure reliable refills.
- Comparison Shop: Use resources like GoodRx to compare prices across pharmacies and find coupons.
- Patient Assistance Programs: Explore patient assistance programs offered by drug manufacturers for discounted pricing.
- Research Health Plan: Contact your insurance to ask which medicines are included on the formulary for chronic weight loss and inquire about your monthly copay.
- Discuss Alternatives: Your insurance may only cover Ozempic when prescribed to treat type 2 diabetes, its FDA-approved use.
- Prior Authorization: If your doctor prefers that you receive Ozempic, they may need to complete a Prior Authorization form to be reviewed and approved by your insurance company.
The Risks of Discontinuing Weight Loss Medications
A study in Diabetes, Obesity & Metabolism found that individuals who stopped taking semaglutide regained some weight and experienced a reversal in blood pressure improvements. While blood sugar and cholesterol levels retained their improvement, the initial weight loss benefits diminished.
Additional Considerations
- Side Effects: Potential side effects of GLP-1 agonists include nausea, vomiting, diarrhea, dizziness, mild tachycardia, and headaches. There are also concerns about anesthesia complications for users of these drugs.
- Off-Label Use: Ozempic use for weight loss is considered âoff-labelâ and is not approved by the FDA. Wegovy, containing the same active ingredient as Ozempic (semaglutide), is approved for long-term weight management but in a higher dose.
- Stimulant Medications: Weight loss drugs that suppress appetite (anorexiants) may contain stimulant medications classified as controlled substances by the DEA due to the risk of abuse and addiction.