The increasing prevalence of obesity and diabetes has led to a surge in the popularity of weight-loss medications, particularly GLP-1 agonists like Wegovy, Ozempic, Mounjaro, and Zepbound. These drugs have demonstrated effectiveness in promoting weight loss and improving blood glucose control, and new research suggests potential benefits for cardiovascular health, osteoarthritis, and even mental health. However, their high cost and the sheer number of people who could benefit from them have created a complex situation for healthcare systems, insurers, and patients alike. This article explores the challenges surrounding insurance coverage for these medications, focusing on Priority Health and Blue Cross Blue Shield of Michigan, and examines alternative options for accessing treatment.
The Challenge of Coverage
Many individuals seeking weight-loss treatment with GLP-1 drugs face significant hurdles in obtaining insurance coverage. Kelly Swayze, a teacher and mother from Trenton, Michigan, experienced this firsthand when her Blue Cross Blue Shield health plan denied coverage for Wegovy. The monthly cost of around $1,300, as quoted via GoodRx, was simply unaffordable.
This experience is not unique. Insurance coverage for obesity treatment with these drugs varies considerably. While many plans cover GLP-1s for diabetes management, coverage for weight loss is often inconsistent or entirely excluded. This is primarily due to the high cost of these medications and concerns about their potential impact on overall healthcare costs.
Dr. Lauren Oshman, program director of the Michigan Collaborative for Type 2 Diabetes, acknowledges the potential of GLP-1 drugs as "lifesavers" for individuals severely affected by obesity and its complications. However, she also recognizes the financial strain that widespread coverage could place on health plans.
The Cost Factor: A Breaking Point?
The high cost of GLP-1 drugs is a major concern for insurers. Dr. Charles Bloom, chief medical officer for Health Alliance Plan (HAP), a subsidiary of Henry Ford Health, estimates that if half of their patient population qualified for GLP-1s, the cost would exceed all acute care expenses, including hospitals, surgeries, and emergency room visits.
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Andrew Witty, CEO of UnitedHealth Group, points out that the US prices for these drugs are approximately 10 times higher than in Western Europe. This pricing disparity has led insurers to seek strategies for managing costs, such as:
- Step therapy: Requiring patients to try less expensive medications first.
- Prior authorization: Implementing strict criteria to identify patients most likely to benefit.
- Exclusion: Completely excluding the medications from coverage.
Blue Cross Blue Shield of Michigan (BCBSM), covering nearly half of Michigan's population, acknowledges the effectiveness of GLP-1s in addressing obesity but emphasizes the need to balance coverage with cost. Atheer Kaddis, vice president of pharmacy services and chief pharmacy officer at BCBSM and Blue Care Network, noted that these drugs doubled their drug cost trends in 2023, resulting in a $400 million increase in spending.
Lifestyle Changes vs. Medication Alone
Insurers like BCBSM emphasize the importance of lifestyle changes alongside medication. Dr. James Grant, senior vice president and chief medical officer of BCBSM, stated that they don't want to simply provide an expensive drug without ensuring patients are also committed to improving their eating habits and increasing exercise.
Consequently, many BCBSM plans require prior authorization and enrollment in a lifestyle-modification program for members approved for GLP-1 coverage. These programs aim to support patients in making sustainable changes to their diet and physical activity levels.
Priority Health's Approach
Priority Health, the second-largest insurance plan in Michigan, covers GLP-1 drugs for diabetes management. However, coverage for weight loss is limited and depends on the plan type and medical necessity of the member. Priority Health recognizes the potential benefits of GLP-1s for weight loss but also acknowledges the remaining questions about long-term safety, efficacy, and affordability.
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To address obesity and diabetes, Priority Health offers its members digital health resources through Virta Health®. These resources include nutrition-first programs and comprehensive, multi-specialty clinical support to help members lose weight sustainably with or without GLP-1s and achieve type 2 diabetes remission by managing blood sugar while reducing medications.
Virta Health offers three programs:
- Sustainable Weight Loss: Helps members lose weight sustainably through nutrition therapy.
- Sustainable Weight Loss with Responsible Prescribing: Includes features of Sustainable Weight Loss and adds optimized GLP-1 use for weight loss via Virta’s Trusted Prescriber Network, with a path to a clinically monitored offramp.
- Diabetes Reversal: Focuses on helping members achieve type 2 diabetes remission through nutrition therapy.
These programs emphasize nutrition therapy and lifestyle changes, personalized to each member’s preferences, budget, and unique metabolic needs. All enrollees have 24/7 access to the tools and resources on Virta’s platform.
The Role of Compounding Pharmacies
Faced with high costs and coverage denials, some individuals are turning to compounding pharmacies for more affordable alternatives. Kelly Swayze, for example, obtains a similar version of Wegovy through a medical spa that uses a compounding pharmacy, paying approximately $300 per month.
When name-brand drugs are in short supply, the FDA allows compounding pharmacies to make similar versions of the drug, provided they meet specific requirements under the Federal Food, Drug, and Cosmetic Act. However, the FDA cautions that it does not review compounded versions for safety, effectiveness, or quality, and some pharmacies may be using different forms of semaglutide that are not equivalent to the active ingredient in Wegovy and Ozempic.
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Medicare and Medicaid Coverage
Medicare plans generally do not cover GLP-1 medications for obesity treatment due to a federal law passed in 2003. However, a University of Michigan National Poll on Healthy Aging found that 83% of adults ages 50-80 believe Medicare should cover FDA-approved weight-management medications.
Most state Medicaid plans also deny coverage of GLP-1 drugs for obesity, but Michigan is an exception. Michigan's Medicaid program covers at least one GLP-1 medication for obesity treatment, requiring prior authorization and limiting coverage to individuals with diabetes or clinical obesity.
Michigan Medicaid began covering GLP-1 weight-loss drugs on February 1, 2022, when a doctor deemed them medically necessary. The state utilizes federal Medicaid matching funds and drug manufacturer rebates to offset the cost of coverage.
Alternative Options and Resources
Given the challenges of obtaining insurance coverage, individuals seeking weight-loss treatment with GLP-1 drugs may explore alternative options and resources:
- Patient Assistance Programs: Many pharmaceutical companies offer patient assistance programs that provide medications at a reduced cost or for free to eligible individuals.
- Discounts and Coupons: Websites like GoodRx offer coupons and discounts on prescription medications, potentially lowering the out-of-pocket cost.
- Employer Wellness Programs: Some employers offer wellness programs that include weight-loss resources and support, potentially covering a portion of the cost of medication or treatment.
- Curex: Curex provides comprehensive care for those suffering from allergies, asthma and eczema. This includes customized sublingual immunotherapy, at-home concierge allergy testing, and symptom management. Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you.