“The Revolution of Weight Loss Drugs: A Battle for Insurance Coverage”

Drugs for weight loss as Zepbound and Wegovy have been heralded as a revolution. However, they are mainly out of reach because to their expensive price and lack of insurance coverage.

TFD – Dive into the world of weight loss drugs, the struggle for insurance coverage, and the challenges faced by individuals in combating the obesity crisis. Discover the ongoing battle for better healthcare access.

Dr. Laure DeMattia, a bariatric medicine specialist in Norman, Oklahoma, understands her patients’ frustrations with their inability to achieve weight loss.

If they could afford it, almost all of her patients at a weight-loss clinic in the suburbs south of Oklahoma City may benefit from the new class of drugs, which included Ozempic and Wegovy.

“My patients have previously completed Nutrisystem and Weight Watchers. They have tried the low-carb, high-protein approach,” she noted. “They’ve already changed their diet and exercise regimen as much as they believed was physically possible.”

A monthly injection of tirzepatide or semaglutide is something that a large number of them have not done. DeMattia can prescribe Zepbound or Wegovy for them, but that’s just the start. After that, they have to fight a difficult and sometimes frustrating battle to pay for the pricey prescriptions.

“Some of the most vulnerable people in our Medicare and Medicaid populations do not have access to any anti-obesity medications,” the spokesperson stated.

In the United States, around half of the adult population is obese or extremely fat. This is a crisis that increases the risk of heart disease, diabetes, and various types of cancer.

The active component of Ozempic and Wegovy, semaglutide, is accessed differently by people based on their race and location, according to recent findings.

An review of over 4 million prescriptions written for semaglutide nationwide in 2023 revealed that around 85% of those prescriptions were filled by white persons throughout the nation. About 12% of the prescriptions were written for Black individuals, who had much higher rates of diabetes and obesity, according to PurpleLab, a health analytics business.

The new family of weight-loss medications, which includes tirzepatide and semaglutide, is increasingly being heralded as a revolution in the treatment of obesity. It has been seven years since semaglutide was approved for the treatment of diabetes. Stars like multibillionaire Oprah Winfrey flaunt their toned bodies while endorsing the medications.

However, the PurpleLab study shows that in 2023, just 1% of Americans with private or public insurance had a prescription filled for semaglutide, the most widely used weight-loss drug.

That was the revolution, for now.

Many of the people who need the drugs the most cannot afford them due to their exorbitant cost. Usually, insurance companies either refuse to pay back the approximately $1,000 monthly cost of the injections or, in the event that they do, place significant obstacles in the way of approving reimbursements.

According to Cleveland Clinic endocrinologist Dr. Peminda Cabandugama, “a lot of what we do with obesity management is more for, I wouldn’t say the elites, but people who actually have better insurance and can get it covered.”

Other weight-loss drugs were not included in the statistics, such as Zepbound by Eli Lilly, which has only been on the market since December, or Mounjaro, the drug tirzepatide’s diabetes variant.

Oklahoma doesn’t even make the top 25 states for semaglutide prescriptions, despite having the third-highest adult obesity rate in the US at 40%.

There is some “weight based discrimination,” according to Dr. Ryan Morgan, an obesity medicine specialist at Vitalis Metabolic Health in Oklahoma, where medical professionals fail to recognize obesity as a chronic illness. He added that he frequently has to inform his patients that many insurers won’t pay for the prescription because it is too costly.

He said, “I could send it and it’s probably going to get denied 99.9% of the time.” “It feels like someone is stealing my tools.”

West Virginia has relatively high prescription rates in comparison to Oklahoma. PurpleLab reports that although the state has the highest rate of adult obesity in the US, it is in second place for semaglutide prescriptions. One possible explanation for the comparatively high prescription rate could be that West Virginia pays for the state employees’ prescription drugs.

That came to an end in February.

The medical weight management program director at West Virginia University, Dr. Laura Davisson, stated that helping her patients afford the medications is a difficult task.

Patients’ inability to pay for care “means we’re going to increase the health care disparities,” even though “we really have it within our power now to potentially turn around the health of this country.”

Investing in ‘the front end’ makes sense.

Heart disease runs in Liz Shumate’s family. She is a 41-year-old mental health therapist from Oklahoma City. Her goal is to shed roughly twenty pounds in order to lower her chance of developing health issues. Numerous diets and other lifestyle adjustments haven’t been successful.

Shumate, a Black woman, attempted to get Wegovy or Zepbound, but her insurance through her employment rejected the prescription and she couldn’t afford the $1,000 monthly cost.

She admitted that those with lesser earnings probably find the situation much more discouraging.

“It just doesn’t make sense when we think about people being able to manage their weight in a healthy way that leads to better outcomes in the long run,” the speaker stated. “There’s a reason insurance won’t pay for it, but we will pay for open heart surgery or other life-saving procedures otherwise. Why don’t we use the cash up front for investments?

Susan Beam, 67, of Norman, Oklahoma, claims that her extra weight has made her rheumatoid arthritis and high blood pressure worse.

Her doctors have recommended a weight loss drug, which she requests to be taken in order to aid with her ailments. But Medicare won’t pay it, so she can’t afford the expensive out-of-pocket medication.

After years of weight struggles, Beam expressed her frustration, saying, “It’s very frustrating.” “If their insurance doesn’t cover it, it’s only available to a select group of people who can reasonably afford to pay for it. That feels unjust, for sure.

Will medication for weight loss ever be covered by Medicare?

According to Cleveland Clinic’s Cabandugama, insurance companies frequently decline to pay for the cost of weight-loss drugs since obesity is still viewed more as a cosmetic problem than a chronic illness.

He mentioned that another obstacle is a 2003 statute that forbids Medicare from paying for medications used to reduce weight, thus alienating a sizable patient base. Private insurance providers frequently follow Medicare’s lead when determining what costs to cover.

“Access has always been an issue,” Cabandugama stated.

Undoubtedly, the Food and Drug Administration’s enhanced clearance of Wegovy to lower the risk of heart attack and stroke may convince more insurers to cover the medications. Pharmaceutical companies are in a hurry to demonstrate that their products offer health advantages beyond diabetes and weight reduction.

According to a spokesman for the Centers for Medicare & Medicaid Services, the FDA’s permission to expand the use of Wegovy to lower the risk of heart attack and stroke is presently being reviewed by the agency.

According to a representative of America’s Health Insurance Plans, or AHIP, a trade association for the insurance sector, an increasing number of employers are thinking about paying for weight-loss medications in the future. According to a 2023 survey referenced by the association, 41% of companies provide coverage for weight loss drugs.

“However, the exorbitant and unsustainable prices charged by manufacturers — more than $1,000 per month — and lack of competition pose continued barriers to access,” the spokesperson said.

It’s over if there is no insurance coverage.

At the Louisiana Center for Bariatrics in Baton Rouge, obesity medicine specialist Dr. Drake Bellanger is concerned about losing patients due to the high expense of the medications.

There will be a sizable percentage of no-shows, he said. Patients simply don’t show up for appointments. And based on what I can see in their chart, those are typically the patients for whom we had to go to more older meds after their previous ones were rejected, and it was evident that they had given up.

According to West Virginia University’s Davisson, the patients she encounters have attempted many solutions but have struggled with weight issues for a lifetime.

“The conversation is usually over if there is no insurance coverage,” the speaker stated. “That is just incredibly disheartening.”