For Debbie Halstead, the weight loss medication Wegovy has been nothing short of a miracle.
The Cool Ridge, West Virginia woman shed 60 pounds and lowered her blood pressure nearly 60 points. What’s more, Novo Nordisk’s blockbuster weight loss drug has relieved the “horrible arthritis in my knees” and made her feel “much, much better,” she said.
But beginning Jan. 1, Halstead’s federal Blue Cross Blue Shield health insurance plan is changing coverage for glucagon-like peptide 1 (GLP-1) drugs such as Wegovy and Ozempic. These drugs will be downgraded to a different coverage tier on her insurance plan.
The drug she now gets for $25 per month will skyrocket to $713 per month.
“Even if I didn’t lose another pound, I’d take this drug as long as I could,” Halstead said. “But at $700 a month, that’s not going to happen.”
Even as weight loss drugs such as Wegovy and Zepbound explode in popularity, many working-age Americans struggle to afford the medications. Some face escalating out-of-pocket costs with higher copays or other cost-shifting from their insurance plans.
Others are denied coverage, forcing them to pay out of pocket, scour for coupons or secure the medication from compounding pharmacies that supply off-brand, discounted and potentially risky versions.
Only about one-third of those prescribed these drugs remain on them for a year or more, even though the medications are intended to be taken for life, like blood pressure drugs, and people who stop them typically regain many of their lost pounds.
For a class of medications that holds so much promise in a nation where 42% of adults have obesity, consumers are frustrated that prices and spotty insurance coverage of GLP-1s have limited their access.
Certain Blue Cross Blue Shield plans have announced they won’t cover the drugs for weight loss at all. States such as North Carolina no longer cover weight loss drugs for those on the state government’s health insurance plan, because of the high costs.
Those who purchase their own health insurance are unlikely to get coverage for anti-obesity drugs such as Wegovy and Saxenda. Just 1% of Affordable Care Act marketplace plans this year covered them, according to a June analysis by KFF, a nonprofit health policy organization.
Medicare, the federal health program for adults 65 and over, restricts coverage to those with diabetes or a heart condition.
On Tuesday, the outgoing Biden administration unveiled a plan to extend obesity drug coverage to more than 7 million Medicare and Medicaid enrollees beginning in 2026. But the rule would need to be finalized after President-elect Donald Trump takes office in January and it’s not clear whether his administration will be willing to shoulder the roughly $40 billion price tag.
Insurance coverage for weight loss is ‘biggest barrier we have’
Too many people struggle to afford the promising class of weight loss drugs due to insurance restrictions, said Dr. Angela Fitch, former president of the Obesity Medicine Association.
Insurance coverage for weight loss “is the biggest barrier we have in the United States because it is not a standard benefit,” said Fitch, who is co-founder and Chief Medical Officer of knownwell, an obesity and primary care provider in the Boston and Dallas regions. Denying weight loss coverage “should be illegal, should be immoral and should be malpractice given the data we have today.”
The high list prices and limited insurance coverage have frustrated consumers.
Halstead, who works at the Veterans Health Administration, received a letter from Blue Cross Blue Shield this month informing her of the price increase for her anti-obesity drugs beginning Jan. 1.
Cool Ridge, West Virginia resident Debbie Halstead worries the cost of her weight-loss drug Wegovy will no longer be affordable due to a change in insurance coverage.
She searched for manufacturer’s coupons to ease the financial crunch she’ll face when the calendar flips to January. Wegovy’s manufacturer, Novo Nordisk, offers a $225 coupon that would knock down her monthly cost to less than $500, which will still be difficult to afford.
Halstead has tried dieting and weight-loss surgery to shed pounds. None has worked as well as GLP-1 drugs, she said. She stopped taking cholesterol medication since losing so much weight, and hopes to discontinue blood pressure-lowering drugs.
She questions whether insurance companies are short-sighted by scaling back coverage for weight loss drugs that could help millions improve overall health and eliminate the need for other maintenance drugs.
“Is it more cost affordable to be overweight and go to the doctor and take medications for all of the co-morbidities that come along with it?” Halstead asked. “Americans are caught in the middle of corporate greed and it is so sad and unfair.”
In a statement, Blue Cross Blue Shield Association said the federal employee insurance program “regularly evaluates the usage and costs of prescription medications and makes changes to the list of covered drugs each year. As we have done for many years, we continue to have access to a range of covered weight loss prescription drugs.”
Anti-obesity drugs costly to employers
Although many consumers face significant out-of-pocket costs, employers are trying to slow the drugs’ runaway costs.
A survey by the benefits consultant Mercer cited the growing use of GLP-1 drugs as a reason prescription drug spending is the fastest growing part of employer health spending. In 2024, prescription drug spending increased 7.7%, slightly less than the 8.4% in 2023.
Boxes of Ozempic and Wegovy made by Novo Nordisk are seen at a pharmacy in London, Britain March 8, 2024. REUTERS/Hollie Adams/File Photo
Nearly all health plans cover GLP-1 drugs for diabetes and a growing share of plans cover the drugs for obesity. In 2024, 44% of all large employers covered GLP-1 drugs for obesity, up from 41% last year, according to Mercer.
Just 5% of companies allowed workers to get GLP-1 weight loss drugs without restrictions, Mercer said. In addition to meeting BMI or weight-to-height ratio thresholds, most employers impose some conditions before employees can qualify for the drugs, such as obtaining authorization before filling a prescription or requiring workers to consult a dietician, for example.
Companies want to limit the number of beneficiaries who might seek out the weight loss drugs for cosmetic or non-medical reasons.
“One way employers responded from last year to this year was to put some guardrails up,” said Beth Umland, Mercer’s research director of health and benefits.
The high list prices of these new weight loss drugs are costly for taxpayer-funded health programs. The Biden administration estimated adding anti-obesity drug coverage for Medicare and Medicaid enrollees in 2026 will cost about $40 billion over a decade. The high price tag prompted some lawmakers to call for more efforts to target the drugmakers prices.
U.S. Rep. Lloyd Doggett, a Texas Democrat, urged Biden administration to address “price gouging” from brand name GLP-1 drugs by authorizing generic competitors. The drugs are currently under patent protection. Wegovy’s isn’t set to expire until 2032 and Zepbound’s in 2039.
Despite the patents, Doggett and other members of Congress have argued the federal government has the authority to authorize generic competitors in exchange for “reasonable compensation” to the brand-name manufacturers.
“Compelling Medicare and Medicaid to offer medications, whose prices they cannot now negotiate, will only bloat spending – costing taxpayers billions, raising premiums, and threatening the long-term security and promise of Medicare,” Doggett said.
High prices prompt consumers to seek alternatives
Amanda Bonello, 35, knew she had to act when recent blood tests revealed her elevated blood sugar put her at risk for diabetes. The Marion, Iowa mother of three worried about her family’s history. Her mom has diabetes, and her dad has pre-diabetes.
Her doctor told Bonello that if she couldn’t reduce her blood sugar, she would prescribe the diabetes drug metformin.
“I was looking for an alternative that would be better,” Bonello said.
So she asked her doctor about the Eli Lilly drug tirzepatide, which is sold under the brand name Mounjaro to treat diabetes and Zepbound for weight loss.
Amanda Bonello, of Marion, Iowa, purchased a less expensive version of the weight-loss drug tirzepatide through a telehealth provider because her insurance does not cover Zepbound, Eli Lilly’s weight-loss drug. She worries an FDA decision to declare Zepbound is no longer in shortage could jeopardize access to less expensive versions made by compounding pharmacies.
Bonello’s workplace insurance plan would not cover Mounjaro because she has pre-diabetes, not full-fledged diabetes. And the insurance plan didn’t cover the weight loss drug Zepbound, which carries a list price of more than $1,000 for a one-month supply. So she found a telehealth provider that could prescribe a less expensive version of the drug sourced from a compounding pharmacy.
She paid $211 out of pocket to get a month’s supply of the weekly injections. She said she could not afford the brand-name drug without health insurance. Customers whose insurance doesn’t cover Zepbound can purchase a one-month supply for $650, Eli Lilly said.
Bonello has been on the compounded version of the drug for one month and has lost 18 pounds. She estimates she’ll need to lose about 50 more pounds to get down to her target weight.
“I feel absolutely incredible,” said Bonello, who said she has more energy, takes frequent walks and keeps pace with her three sons, a 16-year-old and two 12-year olds.
But she’s worried about continued access to the less expensive, compounded version of tirzepatide.
The Food and Drug Administration allows compounding pharmacies to sell copies of drugs when the medications are in short supply. Zepbound and Mounjaro have been in short supply since 2022, but the FDA declared on Oct. 2 the drugs were no longer in shortage. Compounding pharmacies face stiffer restrictions when a drug shortage is resolved. The FDA has also issued a warning against the use of these compounded drugs.
A trade association representing compounding pharmacies sued the FDA, and the agency agreed to re-evaluate its decision to declare the shortage of the two drugs is over. In an Oct. 17 letter, the FDA told the Alliance for Pharmacy Compounding that it would not take any immediate enforcement action.
Still, the uncertainty worries consumers like Bonello who rely on these compounded drugs. In a Change.org petition signed by more than 7,000 people, Bonello and others asked the FDA to preserve access to compounded versions.
“If brand names are the only option, so many people will not be able to afford that, and it would just take hope and health away from so many people,” Bonello said.
Ken Alltucker is on X at @kalltucker, contact him by email at alltuck@usatoday.com.
This article originally appeared on USA TODAY: Weight loss drugs Wegovy and Zepbound too costly for consumers