Insurers Struggle with Soaring GLP-1 Drug Costs, Seek to Wean Patients Off

Why are insurers struggling with GLP-1 drug costs?

Kyra Wensley, a 25-year-old from New York, was shocked when her pharmacy benefit manager denied her request for coverage of the injectable weight loss medication Zepbound. She had been taking the drug without incident for months, but her BMI, which had been around 32 when she started, was now being used as a reason to deny coverage.

Wensley's doctor fought to keep her on the GLP-1 agonist, but she ultimately had to switch to Wegovy, a different medication in the same category, to meet her health plan's requirements. She's not alone - many GLP-1 users are facing similar challenges as insurers struggle to cope with the soaring costs of these medications.

North Carolina Medicaid plans to end GLP-1 coverage for weight loss on October 1, just over a year after starting the coverage. Pennsylvania is planning to limit Medicaid coverage to beneficiaries at the highest risk of complications from obesity. The trend is likely to continue, with state Medicaid programs under pressure due to steep spending cuts in the budget reconciliation package recently signed into law.

What are the alternatives to GLP-1 medications?

Researchers, payers, and providers are now exploring the concept of 'deprescription,' which aims to taper some patients off their medication after they have taken it for a certain amount of time or lost a certain amount of weight. The U.K.'s National Institute for Health and Care Excellence recommends two-year limits on the use of some weight loss medications, such as Wegovy.

A. Mark Fendrick, director of the Center for Value-Based Insurance Design at the University of Michigan, argues that if some people using GLP-1s to lose weight were eventually transitioned off, more people could take advantage of them. 'If you're going to spend $1 billion or $100 billion, you could either spend it on fewer people for a long period of time, or you can spend it on a lot more people for a shorter period of time,' he said.

Studies have shown that people typically regain a substantial amount of weight within a year of stopping GLP-1 medications, and that many people who quit ultimately go back on the drugs. However, companies like Virta Health are promoting behavioral alternatives, such as nutrition-focused weight management programs, as a way to maintain weight loss without relying on GLP-1s.

For some people, like Lily, a transgender woman from Michigan, maintaining weight loss without a GLP-1 remains a challenge. She lost almost 80 pounds on Wegovy, but had to quit the drug when she turned 26 and left her parents' insurance plan. She's tried other medications and lifestyle programs since then, but nothing works as well for her as Wegovy.