Patients navigate an ‘absolutely insane' maze to afford weight-loss drugs

Yahoo

26-05-2025

Laura Davisson is an obesity medicine doctor and professor at West Virginia University, but a growing part of her job is not something she trained for in medical school: looking for the best deal she can get for her patients.
'It's crazy,' she said of the ever-changing insurance landscape for weight-loss medications. 'It's absolutely insane to try to keep up with it all.'
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Across the country, doctors who treat patients for obesity are being forced to develop what amounts to a subspecialty in navigating health coverage for the most popular class of weight-loss medications, known as GLP-1 drugs. The spotty insurance coverage for obesity is dividing patients into classes of haves and have-nots as many insurers throttle back access.
With list prices in excess of $1,000 a month, the cost of a single prescription is not extraordinary for health plans and employers, but the pressure of millions of patients seeking them is creating a major financial drain. So insurers are capping expenses by erecting a variety of hurdles before covering a GLP-1 drug for obesity - or ending coverage altogether.
Doctors and patients are mounting insurance appeals, hunting for lower-cost alternatives and devising strategies to ration doses of their drugs. More patients are turning directly to drugmakers Eli Lilly and Novo Nordisk, which offer discounted cash prices for those who lack insurance coverage. 'The cash-pay option, in my mind, is becoming so much more appealing for people who can afford it,' Davisson said.
Still, the discounted price - which runs to $6,000 a year - puts these drugs beyond the reach of an untold number of patients.
'We're talking about long-term care here. It's very hard for people to afford medicine that costs hundreds of dollars a month,' said Katherine Saunders, co-founder of FlyteHealth and an assistant professor at Weill Cornell Medicine. Insurance coverage for obesity medications 'seems to be getting a bit better,' she said, but the continuous changes have caused anxiety for patients and extra work for clinicians.
The patchwork of insurance coverage means doctors must track changes in coverage and sometimes help patients transition from one drug to another with the shifts, said Jaime Almandoz, medical director of the Weight Wellness Program at UT Southwestern Medical Center.
'What we see is widening disparities in terms of access to care,' said Almandoz, who consults for Eli Lilly and Novo Nordisk. 'It places additional strain on clinical teams that not only delays access to care but really strains the infrastructure of care within the office.'
Patients with GLP-1 prescriptions for obesity filled just 28 percent of them in 2024, while health plans denied coverage for 62 percent of such prescriptions, according to data analytics firm IQVIA. At the same time, the firm clocked a sharp jump in patients paying cash, with 53 percent of prescriptions filled that way, up from 11 percent in 2023.
CVS Caremark, a large pharmacy-benefit manager, this month negotiated a deal with Novo Nordisk to get a discount on the drugmaker's Wegovy in exchange for making it the preferred option on its national menu of drugs covered by commercial insurance. The change will probably force thousands of patients to switch from Eli Lilly's Zepbound, which had superior efficacy to Wegovy in clinical trials.
Blue Cross Blue Shield plans in Massachusetts, Michigan and Pennsylvania are among insurers that have stopped covering GLP-1 drugs for obesity or plan to, citing excessively high costs. The federal Medicare insurance program does not cover the medications for obesity but does cover Zepbound for sleep apnea and Wegovy for reducing cardiovascular risk.
Many patients who lack insurance coverage have turned to cheaper, pharmacy-made imitations of Zepbound and Wegovy that are not approved by the Food and Drug Administration. But these are becoming less available since the agency directed pharmacies to cease making them in bulk.
Davisson, the West Virginia physician, has sometimes resorted to prescribing Ozempic - a diabetes drug that has the same active ingredient as Wegovy - to patients for weight loss because it comes in an auto-injector pen that can be dialed to nonstandard doses to extend its use. The practice, called 'click counting' - in effect, rationing - works only for patients who can lose weight on a smaller dose.
The reckoning over the high cost of these weight-loss drugs has played out most visibly among health plans that cover state employees. North Carolina's health plan stopped covering Wegovy and Zepbound last year for state workers after officials determined they would need to double premiums to pay for GLP-1 costs. Colorado's health plan will cease covering GLP-1 medications for weight loss in July after costs more than quadrupled in the last six months of 2024 from a year earlier, though employees actively taking the drugs will be grandfathered in.
The health insurance industry's trade group, AHIP, said health plans and employers must balance cost and health outcomes. While the weight-loss drugs work well for many, it said in a statement, 'others have difficulty tolerating these treatments, experience complications, or simply choose to discontinue use.'
The Institute for Clinical and Economic Review, which analyzes the cost-effectiveness of prescription drugs, said in an April paper that while the popular obesity drugs 'represent a reasonable value to the health system, the rising tide of GLP-1 use and the scale of potentially eligible individuals has raised serious affordability concerns among both public and private payers.'
These cost pressures are what drove CVS Caremark to strike the deal with Novo Nordisk to cover Wegovy instead of Zepbound. About a third of Caremark's clients have opted not to cover GLP-1 drugs 'because of the high cost of these medications,' Prem Shah, a CVS executive vice president, told financial analysts May 1.
The agreement will save its clients 10 to 15 percent, according to the company. But for patients, it could mean losing less weight.
A clinical trial funded by Eli Lilly found that participants taking its drug, Zepbound, lost 50 pounds on average compared with 33 pounds for those taking Wegovy over 72 weeks.
CVS said that 'clinical trial results often differ from use in a real-world setting' and that it will grant exceptions for 'medical necessity' on a case-by-case basis.
Given such changes, some are ditching insurance and filling their prescriptions directly from drugmakers.
Eli Lilly launched its discounted self-pay option last summer with vials of Zepbound that patients have to draw and inject with syringes, instead of its typical auto-injector pen. The company brought in more than $200 million in revenue during the first three months of 2025 from self-pay patients, who accounted for about 25 percent of new Zepbound prescriptions over that time.
Novo Nordisk launched its own direct-to-consumer pharmacy in March, offering a discounted rate for all doses of Wegovy in its standard pen. On Thursday, the company unveiled a promotion for self-pay patients to get any dose of Wegovy for $200 for the first month, targeting people who had been taking pharmacy-made versions that often sell for that price.
Still, there is a profound difference between paying $500 and having a $25-a-month co-pay, which is what Kevin Sykes had been paying for Wegovy until early this year.
Sykes, a 56-year-old employee of the Defense Health Agency, was prescribed Wegovy to help control his blood pressure. He is covered by the Blue Cross Blue Shield plan for federal workers, which also paid for Wegovy for his wife and daughter.
All of them had lost considerable weight and were happy with the treatment. But the health plan put Wegovy on a less-preferred tier starting this year, which Sykes discovered when his daughter went to refill her prescription and the pharmacy told her it would cost $700.
'She just left it there and walked away,' Sykes said in January.
The Blue Cross Blue Shield plan for federal employees has explained the change by saying that 'the rapid increase in the use of weight loss GLP-1s is the main factor increasing costs' and that it had to make adjustments to maintain its premiums.
Sykes, who has a master's in health care administration, decided to push for a waiver for himself and his family members through their doctors.
When that failed, he and his wife tried a non-GLP-1 drug called Contrave for several weeks at the health plan's insistence. Sykes said he gained back weight and experienced dizziness, and his wife also had side effects.
In late April, the health plan granted Sykes and his wife a tier exception, and they are able to take Wegovy at the previous rate for six months, he said in an interview Friday. Because he has been off the medication for three months, his doctor prescribed him a much lower dose than he had been taking.
'I gained 20 pounds,' Sykes said of the time between stopping and restarting Wegovy. 'My blood pressure went up,' he said, adding that his understanding of the system helped him prevail.
'Some people don't have insight on how health systems work, so they give up,' he said. Switching treatments was 'a needless hurdle.'
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