Does Workplace-Sponsored Insurance Cover Anti-Obesity Medications?

If you’re considering taking injectable anti-obesity medication similar to Wegovy or Zepbound, you may also have to contemplate the price.

The medications, which belong to a category of medication called glucagon-like peptide (GLP-1) receptor agonists, have list prices of over $1,000 per thirty days. While individuals with medical insurance through their employer or the Affordable Care Act (ACA) typically have coverage for medications, fewer than 30% of employers currently cover GLP-1s indicated for weight reduction, based on a fall 2023 survey by the International Foundation of Employee Benefit Plans. When similar medications, like Ozempic and Mounjaro, are prescribed for diabetes, the likelihood of coverage increases to 76%.

ACA medical insurance plans aren’t required to cover anti-obesity medication.

Rick Kelly, National Practice Leader at skilled services firm Marsh McLennan, told Verywell more employers used to cover anti-obesity medication and related diabetes medications, but the recognition of GLP-1s has prompted them to pump the brakes.

“A few years ago, that number was much higher,” Kelly said. “It was probably around 70% to 75% [of employers] before people really understood the financial exposure of covering those drugs.”

Employer Coverage Can Get Complicated

Moving forward, firms that conform to offer insurance coverage for GLP-1s may require employees to finish several steps.

“The query goes to be what processes, what prior authorizations, what utilization management programs will probably be in place,” Kelly said.

For instance, somewhat than simply charging a copay, a workplace insurance plan may introduce its own prerequisites for a BMI threshold, mandate a patient try other medications, food plan, or exercise plans first, and/or require a letter from a physician confirming the patient meets the corporate’s criteria for drug coverage.

Appealing an insurer’s decision to disclaim coverage is feasible. But Kelly said that, in 2024, you’re not prone to have much success. Appeals allow insurers and employers to find out about treatments they won’t have been aware of.

“There are only a few employers within the country who don’t learn about these drugs at this point,” Kelly said. “They have probably already been approached by employees in the event that they’re not covering this drug.”

Will Insurance Coverage For Anti-Obesity Medications Improve?

There are some potential vibrant spots relating to coverage of GLP-1s, but likely not during 2024. For example, while Medicare doesn’t cover weight reduction drugs in any respect—by law, they aren’t permitted to—pending laws called the Treat and Reduce Obesity Act could change that. It will probably take several years to take effect, Juliette Cubanskideputy director of the Program on Medicare Policy at health research firm KFF, told Verywell.

More immediately, recent uses of medicines initially intended for obesity could prompt coverage for those indications. For example, the Food and Drug Administration (FDA) recently added a sign to Wegovy for the prevention of cardiovascular events in individuals who have obesity or chubby and have heart disease. Insurers, including Medicare, at the moment are covering that use.

There are ongoing clinical trials studying the usage of GLP-1 drugs for a spread of conditions beyond obesity, including kidney disease and sleep apnea. FDA approvals of those uses could prompt insurers to cover the drugs for those indications.

“Going forward, it could be harder and harder to not cover them as we see indications expand,” Andrea Dukesvp for health policy on the Center for American Progress in Washington, D.C., told Verywell. “But the costs could also drop as recent weight reduction drugs enter the market, and a number of grow to be subject to Medicare price negotiation, which, if successful, would put downward pressure on the worth of the drugs for other payers.”