Employers Wrestling with Covering Weight-Loss Drugs

The explosion in demand for new, costly and highly effective weight-loss and diabetes drugs is poised to play an outsized role in increasing the cost of health care, and in turn, health insurance in America.

These groundbreaking drugs — the most popular sold under the brand names Mounjaro, Ozempic and Wegovy — are partly to blame for overall pharmaceutical benefit costs jumping 8.3% in 2023, compared to an increase of 6.4% in 2022, according to a report by Mercer.

The effects are amplified because of the high cost of these drugs — around $1,000 a month — as well as the growing legion of patients being prescribed them.

On the other hand, these GLIP-1 drugs, as they are known, show great promise in helping tackle the obesity epidemic in the country, which contributes significantly to medical costs.

They were originally designed to treat diabetes, but they had a surprising benefit: weight loss, sometimes so significant that patients’ glucose levels dropped below diabetic levels, and the medications are now being prescribed for weight loss in patients without diabetes.

Employers and insurers are now faced with the prospect of exploding drug costs if demand continues to boom and doctors write more prescriptions for them. To head that prospect off, they are trying to formulate approaches that could keep costs from spiraling while still attending to the demand for weight-loss regimens.

Booming demand

While Novo Nordisk A/S’s Ozempic and Wegovy have been on the market for some time for treating diabetes, the latter has been approved to treat obesity using smaller doses. While Ozempic has not been approved for weight loss, doctors commonly use it off-label for weight loss as well.

In November 2023, Eli Lilly & Co. won clearance from the U.S. Food and Drug Administration for its new drug called Zepbound — a version of its diabetes drug Mounjaro — to be used to treat obesity.

People who take these medications can see dramatic weight loss, which has spurred a surge in prescriptions. In 2022, 5 million GLP-1 prescriptions were written, a 2,082% increase from 2019. The market for these drugs is expected to grow to between $100 billion and $200 billion a year within the next decade.

The manufacturers have been struggling to keep up with demand, with Novo Nordisk saying it will take two years to build up production capacity to meet demand. As it does that, it has limited the availability of lower starting doses of Wegovy as it prioritizes a continuous supply of the pharmaceutical for people who already use it.

One of the biggest challenges with these drugs is that people who stop taking GLP-1 drugs regain most, if not all, of the weight they lost. That may require a lifetime commitment to taking these medications for some individuals. Also, many people stop taking these drugs because they say they have no longer derive pleasure from eating, rendering dining a boring experience.

What employers and payers can do

While employers cover the use of GLP-1 drugs as a treatment for diabetes, the story changes when covering them for treating obesity.

The list prices for the drugs — before any copays or coinsurance — range from $936 per month to about $1,350.

GLP-1 drugs are already recommended for treating certain high-risk type 2 diabetes cases, the majority of which are due to obesity. It’s likely that many individuals with type 2 diabetes will end up on a GLP-1 drug at some point anyway.

Mercer’s “National Survey of Employer-Sponsored Health Plans 2023” survey of employers with 500 or more workers found that:

  • 35% cover GLP-1 drugs for treating obesity with prior authorization and/or reauthorization requirements.
  • 7% said they cover the drug with no special requirements.
  • 19% said they don’t cover these drugs but are considering it.
  • 40% said they are not considering covering these medications.

According to the Mercer report, some employers have reversed previous coverage of GLP-1 drugs for obesity after utilization spiked, saddling their health plans with a surge in pharmaceutical costs.

For employers who want their plans to cover GLP-1 drugs but need to cap their health care costs, experts recommend a step program for people struggling with obesity as it can help patients lose weight at a lower cost: 

Step one — Focuses on helping the patient change their lifestyle through dietary changes and exercise.

Step two — Focuses on education and ancillary services, such as food delivery or mental health support.

Step three — If they still need help, doctors can prescribe first-generation anti-obesity medications, which are less expensive and often generate satisfactory weight loss.

Step four — If all else fails, doctors prescribe GLP-1s if the plan covers them, fully or partially.

Mercer also recommends that for individuals who have achieved their desired weight loss and health improvements through GLP-1 drugs, physicians may want to consider tapering them off them at some point, while focusing on sustaining the weight loss and improved health through adhering to lifestyle changes.

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