Wegovy (semaglutide) is a self-injectable prescription weight reduction drugs that has helped folks with weight problems. It needs to be used with a weight reduction plan and bodily exercise. (Picture by: Michael Siluk/UCG/Common Photos Group through Getty Photos)UCG/Common Photos Group through Getty Photos
Injectable glucagon-like peptide-1 agonists, or GLP-1s, had been first accredited as diabetes medicines 20 years in the past. They’ve since grow to be in style as weight reduction medication. Taken together with an applicable weight loss program and train routine, GLP-1s are efficient at decreasing an individual’s weight. Nonetheless, insurers within the industrial and public sectors have been reluctant to reimburse them as weight problems medicines. Coverage analysts cite completely different causes for payers holding again, together with the medication’ influence on pharmaceutical budgets coupled with the shortage of short-term value financial savings related to their use. Additional compounding the issue is the absence of enough affected person persistence on the medication: A comparatively giant portion of sufferers discontinue these medicines inside one 12 months, with numbers rising by the tip of years two and three.
Regardless of excessive demand for the brand new era of weight reduction medication, they at present face quite a few industrial insurance coverage protection restrictions. In response to GoodRx, an organization that operates a telemedicine platform that tracks drug costs and gives drug coupons for reductions, the variety of folks with no industrial insurance coverage protection for Zepbound (tirzepatide) elevated by over 180% in 2025. For individuals who have insurance coverage protection, greater than 9 in ten should meet further necessities resembling prior authorization. Although protection for Wegovy (semaglutide) is usually higher than for Zepbound this 12 months, 88% of individuals getting Wegovy by means of their insurer nonetheless face hurdles, together with prior authorization and required protocols by which cheaper remedies have to be tried first previous to gaining entry.
And within the newest survey posted by the Worldwide Basis of Worker Profit Plans in Might, 55% of employers stated they supply protection of GLP-1s for diabetes solely, whereas solely 36% present protection for each diabetes and weight reduction. And of these employers at present providing GLP-1 drug protection solely for diabetes, simply 17% are contemplating reimbursement of medicine for weight problems.
For insurers, the issue with GLP-1s is their giant budgetary influence, generally known as monetary publicity, ought to they cowl them. GLP-1s for weight reduction account for greater than 10% of annual prescription drug claims for employer-based plans that reimburse them, in accordance with current information. Payers don’t take into account this sustainable, because it crowds out their capability to cowl medication in different therapeutic classes. As well as, they’re involved about having to considerably increase enrollee premiums.
And what additional troubles insurers is large-scale research present that GLP-1s don’t result in medical value financial savings, a minimum of not within the brief time period. As an instance, a current research of 23,000 folks on semaglutide-based merchandise throughout a number of payer sorts didn’t discover a decline in medical spending for many who had been prescribed the medicines. The truth is, it elevated. For these sufferers initiated on the GLP-1s, healthcare expenditures rose, with inpatient prices accounting for the biggest share. This was noticed for sufferers with and with out diabetes.
The excellent news from the research is that sufferers skilled enhancements in blood stress, complete ldl cholesterol degree and HbA1c degree, underscoring the merchandise’ affiliation with prevention of heart problems dangers. In addition they misplaced weight, nonetheless, the noticed reductions in routine scientific observe had been smaller than these reported in scientific trials.
The analysis findings spotlight the absence of a connection between scientific advantages and short-term value financial savings, with the research authors concluding: “Our 24-month evaluation didn’t exhibit value financial savings, in distinction to industry-sponsored fashions that challenge long-term financial savings (eg, over ≥10 years) primarily based on trial-derived effectiveness.”
There have been fewer research centered on the extra lately accredited tirzepatide-based drug Zepbound. However, the proof factors in the identical course as for Wegovy: Regardless of providing strong scientific advantages, within the short-term each merchandise aren’t cost-saving due primarily to their excessive value.
For insurers, the elusiveness of short-term financial savings matter, as a result of so many enrollees “churn” by means of completely different well being insurers over time. Payers aren’t essentially incentivized to put money into the longer-term value financial savings present in industry-funded fashions.
Internet costs of branded GLP-1s must come down additional to ensure that them to be cost-saving inside, say, a two-year time interval. Availability of cheaper, generic variations is on the horizon. Furthermore, as a part of the Inflation Discount Act’s drug value negotiation program, the costs of each Ozempic (semaglutide) and Wegovy are at present being negotiated between the Facilities for Medicare and Medicaid Companies and the pharmaceutical large, Novo Nordisk. Their so-called most truthful costs might be publicly posted by early 2026 and carried out in 2027. Although relevant to Medicare, these costs might additionally function benchmarks for payer negotiations in Medicaid and the industrial market.
Nonetheless, even with decrease web costs, medical value financial savings could be predicated on enchancment of ranges of persistence on remedy regimens, together with extra intensive dietary help and life-style administration (weight loss program and train).
There’s some encouraging information on this entrance. The newest Prime Therapeutics research on persistence factors to sufferers more and more staying on GLP-1s for a minimum of a 12 months. Whereas simply over 30% of individuals on Wegovy made it on their treatment to the one-year mark in 2021, the 12 months it was accredited for weight reduction, that determine had practically doubled by 2024. Zepbound, accredited in 2023, had comparable persistence charges. Higher persistence might change payers’ calculations, as they’d be getting an improved return on their funding with fewer sufferers dropping out.
A contemporary evaluation of the scientific and monetary implications of complete protection in Medicare of GLP-1s for all present FDA indications (kind 2 diabetes, weight problems, coronary heart illness and metabolic-associated steatohepatitis) gives some hope for long-term value financial savings. Researchers estimate that if Medicare had been to raise the prohibition on protection of GLP-1s for weight reduction alone and institute broad protection of semaglutide-based merchandise, this might stop practically 39,000 cardiovascular occasions and this system might save over $700 million in web prices over ten years. These advantages are pushed largely by kind 2 diabetes outcomes, the place value offsets from fewer hospitalizations and problems outweigh drug prices.
The research additionally demonstrated scientific advantages for semaglutide-based merchandise used strictly in weight problems care, however the mannequin initiatives added web prices for his or her use in weight reduction alone.
One strategy to circumvent the issue of lack of value financial savings is to higher goal reimbursement by stratifying subgroups of overweight sufferers into these anticipated to learn probably the most versus these for whom the return isn’t pretty much as good. It’s been demonstrated, for instance, that larger financial savings will be attained for these with comparatively larger physique mass indices. If policymakers wish to increase GLP-1 protection to incorporate the weight problems indication in Medicare, Medicaid, or the industrial insurance coverage sector, they’ll want a technique for managing utilization and concentrating on populations probably to learn. This in flip might yield the hitherto elusive value financial savings.
