With roughly two in five U.S. adults affected by obesity, GLP-1 drugs have emerged as a promising solution — but their steep price remains a significant hurdle.
For instance, GLP-1 drugs have a list price ranging from $936 to $1,349 before insurance coverage, rebates or other discounts are applied.
Given the expense, several insurers have decided to stop covering GLP-1s for weight loss, leading to outrage among physicians and advocates, though they are still covering the drug for patients who have diabetes.
This has prompted at least one interviewed for this story to say comprehensive coverage in terms of an executive order from the White House may be what is necessary to make sure this drug is available to those who need it.
Starting January 1, Blue Cross Blue Shield of Massachusetts (BCBSMA) will no longer cover GLP-1s for weight loss for employers with fewer than 100 employees. Employers with more than 100 employees can choose to cover these drugs at an additional cost. BCBSMA’s policy applies to self-insured and fully-insured employers.
“We’ve made this decision after careful consideration and to be responsive to customers who’ve expressed to us that they are no longer able to bear the burden of paying for these high-priced medications,” said Kelsey Pearse, a spokesperson for BCBSMA.
Harvard Pilgrim Health Care — an insurer in Maine, Massachusetts, Rhode Island and New Hampshire — is also ending GLP-1 coverage for weight loss for most commercial plans starting January 1. Large fully-insured employers with more than 100 employees can opt to pay to continue coverage. Members of these plans will be required to complete a six-month behavioral modification program before accessing the medication, unless they are already using it.
“Given [the] current pipeline of pending future FDA approvals of weight loss medications for alternative indications including cardiovascular conditions and other comorbidities, this action is being taken to ensure affordability of coverage for all our members,” a Harvard Pilgrim Health Care spokesperson, who declined to be named, said.
In other words, costs are only expected to increase with these additional FDA approvals down the line.
While no definitive number is available to show how many insurance companies and employers are dropping coverage, here are few others that have announced ending coverage for GLP-1s for obesity: Blue Cross Blue Shield of Michigan, RWJBarnabas Health for its employees and Ascension for its employees.
Medicare also does not cover GLP-1s for weight loss, and some state Medicaid programs are rolling back coverage, including North Carolina. Former President Joe Biden proposed a rule that would have expanded coverage of these drugs under Medicare and Medicaid, but the Trump administration chose not to finalize the rule.
When it comes to self-insured employers, 73% are covering them for obesity, while 99% are covering them for diabetes, according to a recent survey from the Business Group on Health. To manage costs, some employers are implementing cost-cutting strategies like a higher body mass index threshold for coverage.
When asked about insurers rolling back coverage of GLP-1s for weight loss, a spokesperson for AHIP said, “obesity is a complex, chronic condition that affects millions and requires individualized care.
“While GLP-1s have emerged as a treatment option for some patients, they are not universally appropriate and can present risks or challenges,” said Conner Coles, the spokesperson. “Health plans continue to assess clinical evidence and work with experts to support coverage policies that prioritize safe, effective, and clinically appropriate care for weight loss.”
What advocates and physicians are saying
While insurers may be ceasing coverage of GLP-1s for obesity due to cost challenges, one obesity medicine physician said this is a dangerous game. She noted that while obesity often contributes to numerous other health conditions, the industry typically covers treatments for those conditions — but not obesity itself.
“I think it’s the wrong thing to do. I mean, it’s malpractice, if insurance companies could be held to malpractice standards. If I have a patient with obesity today and I’m seeing them, and I don’t recommend that they go on this type of treatment, I think you could consider it malpractice today, given the data that we have [on how well these drugs work]. Especially if that patient had multiple other issues that they had along with their obesity,” said Dr. Angela Fitch, co-founder and chief medical officer of metabolic health company knownwell. Fitch is also the former president of the Obesity Medicine Association.
Fitch added that when her patients don’t have coverage for GLP-1s, she has to advise them to pay cash and go through manufacturers’ direct-to-consumer options (Novo Nordisk’s NovoCare or Eli Lilly’s LillyDirect). Or she has to switch them to an older medication that requires more visits and potentially more side effects.
A healthcare advocate also expressed concern over insurers’ decisions to cease coverage of GLP-1s for weight loss. Millicent Gorham is the CEO of the Alliance for Women’s Health and Prevention and leader of the EveryBODY Covered campaign, which is pushing for comprehensive coverage of obesity care. She noted that women living with obesity often face discrimination in the workplace, earn less money than their colleagues and are less likely to be promoted.
“To see insurers roll back coverage of these evidence-based therapies is deeply concerning, as these decisions reinforce the culture of stigmatization for women living with obesity, while also exacerbating health complications associated with the disease,” she said. “We as a society need to break from the misguided belief that obesity is a result of ‘poor lifestyle choices.’ Obesity management medications aren’t ‘vanity drugs,’ they are critical interventions for a serious chronic disease.”
Gorham added that if insurers care about cardiovascular disease, diabetes and cancer, then they should care about obesity too. Covering these medications leads to fewer emergency room visits, fewer surgeries and lower rates of disability and absenteeism, she argued.
According to DoseSpot, which offers software to providers to help them manage prescription ordering, the rollback of coverage is creating a lot of uncertainty for patients and providers. That’s why the company is using its platform to inform providers and patients of what financial assistance programs there are.
“We’re bringing more power into the patient’s hands, advocating for their ability to see pricing of medication and shop pharmacies that might have the medication at a cheaper price or more convenient, whether it’s mail order or an in-person pharmacy counter experience,” said Josh Weiner, CEO of the company.
What manufacturers are saying
The manufacturers of weight loss drugs are also calling out insurance companies for rolling back coverage of GLP-1s.
“We are disappointed by decisions that limit access as it is contrary to actions that many throughout our country are taking to expand coverage for GLP-1s for weight management, recognizing the importance of these medicines for people living with obesity,” said Allison Schneider, director of media relations at Novo Nordisk. “We believe that comprehensive coverage through government and commercial insurance plans is critical to providing more people living with obesity access to affordable healthcare and treatment options.”
Eli Lilly, which manufactures Zepbound and Mounjaro, similarly criticized insurers’ actions.
A spokesperson who declined to be named said obesity is a chronic disease and should have comprehensive coverage like other diseases.
“Gaps in insurance coverage disrupt effective care and limit access to safe, evidence-based obesity management medications,” the spokesperson said. “Lilly believes access should be guided by clinical evidence, not insurance design.”
It’s worth noting, however, that manufacturers aren’t necessarily blameless in this issue, as they’re the ones pricing the medications. Data from one study shows that Ozempic can be manufactured for less than $5 a month, but costs about $500 through NovoCare.
What needs to happen
While there were efforts to expand coverage of GLP-1s under Medicare and Medicaid — which in theory would encourage more employer-sponsored coverage — this wouldn’t be enough, according to Fitch. If Medicare were to start covering GLP-1s, it would take a couple of years for that to take effect, and then a few more years for commercial insurers to follow suit, she argued. Instead, there needs to be an executive order from the White House that makes obesity treatment a standard benefit, she said.
“Our health system is not designed to make people well or prevent disease,” she declared. “It’s designed to treat disease after it’s already happened. But we’re in a new era now where we can actually treat the root cause of disease, which is obesity, and prevent all these other diseases, but we need some sort of urgent public health action.”
So while Trump could be the hero, that doesn’t mean payers should wait around for federal action. She also called on insurers to step up.
“They could be the hero right now. We need a hero in obesity … because we have revolutionary treatment in our hands as clinicians, and we need the ability to get it out to people,” Fitch said.
Photo: Jason Dean, Getty Images
