Limited coverage of weight-loss drugs could fuel health inequities

Key takeaways:

• Some health insurance companies are limiting coverage of pharmacologic obesity treatments.
• Patients from underrepresented racial and ethnic groups are particularly vulnerable to coverage barriers.

The AMA has adopted a policy in support of insurance coverage parity for evidence-based weight-loss medications “without exclusions or additional carve-outs,” the organization recently announced.

The new policy comes amid reports that some health insurance companies are enforcing stricter coverage requirements for weight-loss medications, and some employers are stopping their coverage altogether, according to reporting by STAT.

Weight-loss medications are also limited in government programs. CMS is unable to cover them due to a 2003 law that established the Medicare Part D prescription drug benefit.

Meanwhile, out-of-pocket costs for these medications are not likely sustainable for most patients. According to the Peterson-KFF Health System Tracker, the costs of weight-loss drugs are:

• $936 for Ozempic (semaglutide 1 mg, Novo Nordisk);
• $936 for Rybelsus (semaglutide 7 or 14 mg, Novo Nordisk);
• $1,349 for Wegovy (semaglutide 2.4 mg, Novo Nordisk); and
• $1,023 for Mounjaro (tirzepatide 2.5 mg, Eli Lilly).

Experts said the high costs and lack of coverage could have wide-ranging implications, particularly when it comes to addressing the obesity epidemic in the United States and ensuring equitable health.

Health inequities

Recent research has shown that semaglutide could halve obesity prevalence in the U.S., where one in three adults is overweight, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

Low-income patients and certain racial and ethnic populations with overweight or obesity could be more impacted by the absence of coverage than others, “especially as Black and Hispanic people experience obesity and associated conditions at higher rates than white people,” said Marcus Schabacker, MD, PhD, president and CEO of ECRI, a health care technology and safety nonprofit organization.

“Furthermore, should one’s diet be high in processed foods, the risk for obesity and diabetes is increased further,” he told Healio.

Other health conditions that could be helped by weight-loss medications may be left untreated, “particularly when it comes to secondary diseases such as diabetes, CVD, hypertension, as well as skeleton muscular issues like hip or knee joint issues,” Schabacker said.

“In their attempt to avoid covering these drugs in favor of short-term financial interests, insurance companies may be setting themselves up to pay for exponentially more expensive treatments down the road in a nation where nearly half of adults are living with obesity,” he said. “So, not covering those widely is actually bearing a higher cost at the end because we then have to pay for the treatments of those secondary diseases.”

Lower-cost alternatives

Rebecca Andrick, DO, CNS, FOMA, a bariatric medicine specialist, told Healio that for patients whose medications like semaglutide are becoming too expensive, “there are some lower cost options that they probably should pursue and think about staying on long-term to maintain that weight that they've lost,” she said.
that several medications have been approved for obesity, “and a couple of the combination drugs that we use can be prescribed generically, so sometimes the medication can be fairly inexpensive.”

Such combinations include naltrexone hydrochloride and bupropion hydrochloride (Contrave, Orexigen), “and people can get those from a mail order pharmacy for $99 a month,” she said.

So, in addition to physical activity, “I would suggest trying to see if patients are good candidates for these other medications, because the other thing we know about obesity is that it's not just a chronic disease — it's a chronic and relapsing disease.” Andrick said.

References:

• AMA urges coverage of obesity treatments as payers balk at costs. https://www.statnews.com/2023/11/13/weight-loss-drugs-wegovy-zepbound-ama-insurers/. Published Nov. 13, 2023. Accessed Dec. 13, 2023.
• AMA urges insurance coverage parity for emerging obesity treatment options. https://www.ama-assn.org/press-center/press-releases/ama-urges-insurance-coverage-parity-emerging-obesity-treatment-options. Published Nov. 14, 2023. Accessed Nov. 26, 2023.
• Compilation Of the social security laws. https://www.ssa.gov/OP_Home/ssact/title18/1860D-02.htm. Accessed Dec. 12, 2023.
• Employers cut off access to weight-loss drugs for workers. https://www.wsj.com/health/healthcare/employers-cut-off-access-to-weight-loss-drugs-for-workers-cb277a44. Published Aug. 2, 2023. Accessed Dec. 12, 2023.
• How do prices of drugs for weight loss in the U.S. compare to peer nations’ prices? https://www.healthsystemtracker.org/brief/prices-of-drugs-for-weight-loss-in-the-us-and-peer-nations/. Published Aug. 17, 2023. Accessed Dec. 12, 2023.
• Overweight & obesity statistics. https://www.niddk.nih.gov/health-information/health-statistics/overweight-obesity. Accessed Dec. 12, 2023.