GLP1s increasingly not covered by insurance?

GLP1s increasingly not covered by insurance?
Photo by Scott Graham / Unsplash

You'd think that GLP1 Receptor Agonist treatments, which help treat type 2 diabetes and help with weight management (and thus avoid some bad potential outcomes like Heart Disease or Diabetes) would be loved by insurance companies.

Don't know what a GLP1 Receptor Agonist is, or how drugs like Ozempic, Mounjaro, Wegovy, or Zepbound work?

Check out our quick explainer

Turns out insurance companies are removing it from coverage at alarming rates, often due to cost.

Insurance providers that have removed Ozempic or other GLP1 drugs

We know that Ascension has dropped coverage of Ozempic and other (including future) GLP1 RAs for it's employees:

Ascension drops weight loss drug coverage for employees
Ascension, one of the largest employers in the US, has dropped coverage for weight loss drugs such as Wegovy. Employees must now pay out-of-pocket for

UT SELECT and UT Care prescription drug plans, administered by Express Scripts have dropped Wegovy and Saxenda for weight loss and weight loss management:

UT Select prescription plan GLP1 coverage cancellation announcement

Plans that are covering GLP1 drugs (ex. Medicaid)

Right now, the biggest health plan that is guaranteed to be covering a drug like Ozempic is Medicare โ€“ but not for weight loss. Confused? We'll explain.

The University of Michigan has a great guide on this:

Medicare doesnโ€™t cover obesity drugs, but 76% of older adults think it should | Family Medicine | Michigan Medicine
Read the original story by Kara Gavin on the Institute for Healthcare Policy and Innovation website here. The vast majority of older adults โ€“ 83% -- think health insurers should cover medications that can help people with obesity manage their weight, a new poll of people age 50 to 80 finds. Nearly as many -- 76% -- believe Medicare should cover these drugs, which it cannot

The important bit:

A law passed in 2003 prohibits Medicare from covering weight loss medications, though it can cover drugs to help people with Type 2 diabetes manage their weight.

Medicaid covers obesity medications for adults with low incomes in 15 states. Most private plans and the Veterans Health Administration cover them, but with restrictions due to high monthly costs for the new generation of medications.

This means there's a difference between a drug like Ozempic which is FDA approved for treating type 2 diabetes, and Wegovy, which is approved for weight management/weight loss.

That said we know that Medicaid Part D (drug coverage) was actually modified to include GLP1 drugs.

That said, states are free to choose whether they cover the drugs or now, so there is some discrepancy โ€“ some states have states have committed, and others haven't:

US Medicaid coverage graph for GLP1 (Source: Milliman White Paper)

There are great sources out there cataloging the rise in prescription and use of GLP1 Receptor Agonists like Ozempic, Wegovy, Mounjaro, Rybelsus and others:

Medicaid Utilization and Spending on New Drugs Used for Weight Loss | KFF
This brief discusses Medicaid coverage of weight-loss drugs, recent trends in Medicaid utilization and gross spending on new drugs used for weight loss, and the potential implications of those new drugs for Medicaid programs and enrollees.

Looking at the chart that KFF produced:

Medicaid utilization and gross spending on wegith loss drugs (source: KFF)

What this doesn't show is the actual rate of prescriptions, which is also huge, and put together by Axios:

Rate of GLP1 prescriptions graphed by state (source: Axios)

So in the future, it's likely that more and more states will start to include the drugs in medicare, as more seniors and other citizens demand them.

So what? Cost is still the issue

Price and availability are still the key determining factors for whether GLP1 Receptor Agonists like Ozempic, Wegovy, Rybelsus and others can be added to health insurance plans and national options like Medicare.

Health plans like those at UT are unlikely to continue offering medication like Wegovy which are for weight management (rather than type 2 diabetes strictly), unless the prices are in line with what they can budget.

Even if on Medicare, since states are free to choose/manage which medications they support and offer under Part D, the importance of price is a major factor in the decisions of states to carry the drug or not, even with the federal rebate.

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