While the availability of popular weight-loss medications is on the rise, obtaining them is still a complex process. Many employers and insurers are reducing coverage for medications like Wegovy and Zepbound, and Medicare does not include coverage for obesity drugs. Although some large employers are expanding coverage, it is not a guaranteed benefit.
The high costs of these treatments, which can amount to hundreds of dollars per month even with discounts, pose a barrier for many individuals seeking these medications. The ability to achieve significant weight loss, which is often life-changing for patients, is heavily reliant on the type of insurance coverage they have and its duration.
In the U.S. healthcare system, coverage issues are common, but they are particularly challenging for obesity treatments due to the broad eligibility criteria for potential patients who may benefit from these drugs. Furthermore, patients are required to maintain consistent usage of the medications to sustain weight loss results.
Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation, noted, “There are many individuals who are eager to access these medications but are unable to do so.”
Coverage disparities exist based on the payer. For instance, Paul Mack experienced a significant weight loss while using Wegovy, which was covered by California’s Medicaid program. However, he lost coverage when his income increased, leading to weight gain. The inconsistency in coverage extends beyond individual cases, with only a fraction of insurers and employers offering comprehensive coverage for obesity drugs.
Moreover, concerns around costs and the uncertainty of the drugs’ efficacy are prompting payers to reconsider their coverage policies. Restrictions such as prior authorization requirements are common, and the lack of Medicare coverage poses challenges for individuals transitioning from employer-sponsored plans.
Despite the potential benefits of these medications, payer concerns about escalating costs are driving decisions to limit coverage. Researchers and experts, such as Dr. Katherine Saunders from Weill Cornell Medicine, emphasize the importance of planning ahead for individuals transitioning to Medicare to mitigate coverage gaps.
The future of insurance coverage for weight-loss drugs remains uncertain, especially as drug availability increases. The pivotal question is how long employers will sustain coverage, given the financial implications. Stacie Dusetzina, a health policy professor at Vanderbilt University, raises concerns about the sustainability of coverage expansions amidst rising spending projections.
While drug manufacturers highlight the potential savings associated with these medications, challenges in insurance coverage and affordability continue to hinder access for many individuals seeking effective weight-loss treatments.
Providing by enhancing patient health and preventing future severe medical conditions such as heart attacks or strokes. However, healthcare professionals emphasize that there are no guarantees that the employer or insurer covering the drug will ultimately benefit from these advantages because individuals may switch jobs or insurers. Will there ever be consistent coverage? The journey toward widespread coverage of obesity drugs remains unclear, despite polls showing that Americans support having Medicaid and Medicare cover the expenses. Eli Lilly, the manufacturer of Zepbound, has observed a gradual increase in coverage for their drug and expresses optimism for its continuous growth. The former President Joe Biden’s administration proposed a regulation that would enable Medicare and expanded Medicaid coverage, but its outcome is uncertain under President Donald Trump’s administration. A bill advocating for Medicare coverage has been circulating in Congress for years, although it is not slated for a vote. Current drug manufacturers are testing multiple additional treatments for obesity. Potential competition could potentially lower prices and encourage broader coverage. Inconsistent coverage complicates treatment plans, as Dr. Amy Rothberg highlights the dilemma of prescribing medications due to uncertainty about how long patients can access the drug. She acknowledges that individuals often discontinue these medications and regain weight based on research findings. Dr. Lydia Alexander, president of the Obesity Medicine Association, notes that some insurers mandate dietary and exercise modifications before approving coverage for weight-loss medications. These changes should coincide with commencing the medication. Additionally, certain insurers require a body mass index of 40 or higher, indicating severe obesity, to initiate coverage. Dr. Alexander emphasizes that although obesity is recognized as a disease, the treatment approach does not align with this classification. The Associated Press Health and Science Department is supported by the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.
