Here’s what it takes for insurance to cover weight loss pills

The makers of Ozempic, Wegovy and Mounjaro are racing to prove that these hugely popular drugs offer health benefits beyond weight loss and diabetes. They say doing so would make it easier for patients to get insurance to cover expensive drugs.

Clinical trials are underway to see if the drug can reduce the risk of heart attack, stroke, kidney disease and other chronic diseases in obese people.

Although obesity is associated with a number of health risks, insurance companies typically do not cover the cost of weight-loss medications, which can exceed $1,000 for a month’s supply.

Dr. Peminda Cabandumanga, an endocrinologist at the Cleveland Clinic, said the reason why it’s not covered is because there’s a perception that obesity is considered a cosmetic problem rather than a chronic disease. count. But these drugs not only help with weight loss, they also benefit the heart, help regulate blood pressure, help lower cholesterol and eliminate sleep apnea.

Another barrier is a 2003 law that prohibits Medicare from covering weight-loss drugs, eliminating a large number of potential patients. Private insurers also often take their cues on what will be covered from the federal program.

“We found that these drugs were priced very high by pharmaceutical companies,” said Dr. Beverly Tchang, an endocrinologist at Weill Cornell Medicine in New York. Coverage and access will certainly be the biggest challenges as we move forward with treating people with obesity.

Benefits beyond weight loss

In August, Novo Nordisk, the maker of Ozempic and Wegovy, became the first to demonstrate in a large clinical trial that the drug offers health benefits beyond weight loss and diabetes control. In a phase 3 trial of more than 17,000 obese adults, Wegovy was shown to reduce the risk of cardiovascular events, such as heart attacks and strokes, by 20%. (Ozempic, approved for Type 2 diabetes, and Wegovy, approved for weight loss, both contain the same drug, called semaglutide.)

Tchang said that while previous clinical trials of drugs like semaglutide for diabetes and weight loss showed that the drugs also improved blood pressure and cholesterol, two risk factors for heart disease, the Bureau The Food and Drug Administration needs independent studies looking at heart health so a company can say a drug has that effect.

Last week, Novo Nordisk announced results from another clinical trial showing that Ozempic slows the progression of kidney disease in patients with Type 2 diabetes.

Eli Lilly, the maker of the diabetes drug Mounjaro, expects to receive the weight-loss drug late this year or early next year. On Sunday, at the Obesity Week 2023 conference in Dallas, Lilly presented full results from the SURMOUNT-3 trial, which showed that people who took tirzepatide, the drug found in Mounjaro, after 72 weeks lost more weight than those taking the placebo. Both groups were asked to make intensive lifestyle changes, including following a low-calorie diet, exercising and attending weekly counseling sessions 12 weeks before starting the medication.

Lilly also hopes to win approval for another weight-loss drug, called retatrutide, within the next few years.

At the same time, the drugmaker is also conducting several clinical trials to see whether its drug can treat obstructive sleep apnea, non-alcoholic fatty liver disease and other chronic diseases. Are not.

“There are a lot of possible benefits,” Dr. Nadia Ahmad, medical director of obesity clinical development for Eli Lilly, said of the drug. After weight loss, “there were further cardiometabolic benefits, blood pressure decreased further, insulin levels decreased further, lipids improved further.”

Ahmad said the clinical trials will provide important insights for doctors treating patients, as well as for insurance companies and governments when determining whether to include weight-loss drugs in coverage. their danger or not.

“All this data helps inform decisions, whether that decision is made by the provider or the government,” she said.

Cut out of coverage

Mike Bergmann, 38, of Fort Myers, Florida, was initially lucky to get insurance to cover his Wegovy prescription.

Bergmann said that despite running about 4 miles a day for about a year, he struggled to lose weight until he started taking Wegovy in December.

“I thought, I’ll try this,” he said. I work as a mortgage loan officer, so I’m in the office pretty much from early morning until late at night.

In just a few short months, he said he lost about 50 pounds and lost the desire to drink.

He said he might have lost more weight if his insurance hadn’t suddenly stopped covering his prescriptions over the summer. The insurance company stated that the drug was not medically necessary and instead recommended diet and exercise.

Without insurance, he couldn’t cover his out-of-pocket drug costs of about $1,300 a month.

But Bergmann says he’ll keep doing it if he can.

The tide may be changing

There are some signs that insurers and lawmakers may be warming to the idea of ​​covering weight-loss drugs.

In 2021, House lawmakers introduced the Obesity Treatment and Reduction Act, which would allow the federal government to expand Medicare Part D coverage to include weight-loss drugs. According to, the bipartisan legislation had 154 co-sponsors, but failed to receive a vote in the House before the end of the term.

Furthermore, the Congressional Budget Office said this month that it is calling for new research to support the use of weight-loss drugs under Medicare as well as the potential savings they could provide.

Employers may also be willing to pay for diet pills. (Because most Americans get their health insurance through work, employers play an important role in deciding what the company plan will cover.)

Research presented Monday at the Obesity conference found that human resources directors and benefits consultants have an overwhelmingly positive view of weight-loss pills, agreeing that the drugs can help employees feel better. better weight control and improve their overall quality of life.

However, the findings based on a survey conducted from May to December 2022 also indicate that these executives and consultants want more data on additional health benefits of drugs to ensure high costs before providing insurance to their employees.

“HR benefits experts really see a potential role in improving and treating obesity as well,” said Dr. Kimberly Gudzune, associate professor of medicine at Johns Hopkins University School of Medicine. as well as other related conditions as well as improving the quality of life for employees. are presenting the findings. “But now we’re really looking at it and hopefully have more information on that financial aspect.”

Meanwhile, Gudzune said employees, even at smaller companies, can benefit from talking to HR representatives about why they don’t cover diet pills.

“I think employees have a role to play in advocacy,” she said.

According to NBC HEALTH ABOVE Twitter & Facebook.

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