‘Obesity has a bad name’: Why it’s so hard for many to get new, pricey weight-loss drugs covered by insurance | Lehigh Valley Regional News

EMMAUS, Pa. – Doctors are finding drugs used for diabetes patients have been highly effective for those struggling to lose weight. In fact, the FDA recently approved the same type of medications that were originally prescribed for diabetics, specifically for weight control. But the out-of-pocket costs can be staggering, for those with insurance that won’t cover it.

“Rather than just looking at a person and saying, ‘Well, maybe if you got on the treadmill, maybe if you lifted some weights,'” Becki Schaffer said. “There’s way more to it than that.”

Schaffer, who lives in Emmaus with her husband and four kids, says she’s struggled with her weight her entire life.

“Always on the heavier side,” she said. “I never really figured out why because I didn’t really eat necessarily bad, was super active, in lots of sports and everything like that.”

As time went on, checkups revealed more.

“Come to find out like there was underlying things like PCOS,” she said.

Polycystic Ovary Syndrome comes with symptoms like weight gain, according to Johns Hopkins Medicine.

“And my A1C was always just a little bit higher.”

That means she’s prediabetic. By her fourth child, she says her hormones had been through the wringer.

“I could literally run on the treadmill, 20 hours out of the 24 hours a day, and it, it doesn’t just fall off, like some people,” she said.

Schaffer recently learned about GLP-1 drugs, like Ozempic.

Adam Biener is an assistant professor of economics at Lafayette College. He’s also a former paid consultant for Novo Nordisk, which makes Ozempic and Wegovy.

“GLP-1 or glucagon-like peptide agonists are medications that were originally developed to treat diabetes,” Biener said.

Doctors say GLP-1 drugs, like Ozempic, initially created for treating diabetes, have been extremely effective for those with underlying conditions trying to lose weight.

“They’re having to use none or less medicine of other types to treat their diabetes,” Dr. Tim Law, Chief Medical Officer of Highmark, Inc. and a practicing physician in Kentucky, said. “But then lo and behold, at the same time, they’re losing, you know, 40 pounds in six months.”

Doctors say drugs, like Ozempic and Mounjaro, are labeled for diabetics. But others, like Wegovy and Saxenda, have recently been FDA-approved specifically for weight loss.

For people like Schaffer, it could be a game-changer.

“If you have a car and the engine is broke, well yeah, you can push it around,” she said. “But if you don’t fix the engine, it’s not going to drive.”

But the drugs are far from cheap, costing up to thousands of dollars, thanks to an explosive demand.

“Monthly injections that can cost over $1,000 a month,” Biener said. “So, when you’re talking $12,000 a year for the maintenance of the medication.”

Like many others, Schaffer’s insurance only covers diabetic medications that don’t help with weight loss.

“I had all my doctors fax over, you know, all the information of my PCOS and my weight gain and everything like that,” she said. “And it’s like, they just, they were like, ‘Well, too bad.’ You know, they don’t care.”

Some patients say they’ve had luck with coupons, like one for Ozempic or GoodRX.

Schaffer says her state insurance doesn’t allow her to use certain coupons. But losing weight for her and many others is so much more than a vanity issue.

“It’s affecting your heart, it’s affecting your liver, your kidneys,” she said. “It’s affecting your joints.”

That’s why these new medications could be a game changer. So why are there so many roadblocks?

“Historically, drugs or treatments that are considered cosmetic, are typically not covered by insurance,” Biener said.

Biener says since the drugs are so new and complex, as of now, they’re only prescribed by a doctor.

“And so you have a lack of cheaper substitutes that you can go to that are equally effective,” he said.

And these high prices are why, experts say, it may be so hard to get it covered through your insurance: because the companies have to pay those large sums.

“Unfortunately, obesity has a bad name, right,” Dr. Law said. “If you have a small company with, you know, 50 employees, and you’re trying to get insurance for everybody, maybe this is one of the things that you cut out.”

Law says about 88 percent of GLP-1 prescriptions that make it through his company are for diabetes. Just 12 percent are for weight loss.

“But you have to meet certain criteria, you know, your BMI has to be above a certain level at that kind of thing,” he said.

Law says certain guardrails are in place to ensure the patient isn’t just using the medicine for cosmetic reasons. Still, some say there are too many requirements that keep those who really need the medicine from getting it.

“Make it more difficult or limit the cases in which they will cover,” Biener said. “You need to have some other comorbidities, say diabetes, or coronary heart disease or something like this.”

Experts say with the novelty and demand of the drugs right now, there’s not a lot that can be done until they become more widespread.

“So, we’re really between a rock and a hard place,” Law said. “You can get it much cheaper in other countries. I know. But they’re having even more supply chain issues than we are.”

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