Starting within the new yr, Independence Blue Cross, the area’s largest well being insurer, will not cowl anti-obesity medication like Ozempic and Wegovy after they’re prescribed solely for weight reduction.
The medication’ excessive prices have brought about a rise in premiums that “have an effect on all members, whether or not they make the most of weight reduction medication or not,” IBX stated in an announcement Tuesday.
The choice was posted on IBX’s website in November and drew local press protection this week. The firm famous that a number of different insurers have made comparable selections in latest months when it introduced the change final month.
“The value of those medication within the U.S. is sort of 10 occasions greater than different components of the world and that has made it extraordinarily difficult to have the ability to proceed to offer protection to everybody who needs to shed some pounds or can profit from the medication,” the corporate stated.
Without insurance coverage, the medication can value $1,000 or extra a month. Wegovy, for instance, prices as low as $92 a month in the United Kingdom however $1,349 within the United States, NBC reported.
The excessive costs within the United States spurred a Senate listening to this fall that drew consideration to the nation’s complex drug pricing system. A relative lack of market competitors, unique patents, and the negotiations between insurers, drug firms, and the profit managers concerned as middlemen have all acquired scrutiny and might contribute to higher drug prices.
IBX’s choice applies to all medication prescribed solely to assist a affected person to shed some pounds and to not deal with every other situations. The rule takes impact on Jan. 1.
That features a class of extraordinarily in style medication often known as GLP-1 receptor agonists, now prescribed to about one in eight American adults. They mimic the results of the GLP-1 hormone to manage blood sugar ranges. Some are accredited by the Food and Drug Administration solely to deal with diabetes or cardiovascular disease, however others are accredited to encourage weight loss as well.
Many docs have prescribed them to sufferers who’ve struggled to shed some pounds and say such drugs have changed their lives. In areas the place insurers beforehand have dropped protection, many sufferers and physicians have criticized that call as shortsighted. They say it cuts off sufferers from medicines that usually enhance their well being extra successfully than other drugs or lifestyle changes alone.
The American Diabetes Association has warned that abruptly stopping such medications might trigger sufferers to achieve weight once more and improve their danger for diabetes and coronary heart situations, the New York Times reported.
Still, different sufferers have raised considerations in regards to the medication’ probably dangerous results: In Philadelphia, a federal courtroom case is underway in opposition to main GLP-1 drug producers, introduced by sufferers who say the businesses did not adequately warn them of serious side effects.
Exorbitant costs
In its last weeks within the White House, President Joe Biden’s administration final month signaled assist for expanded insurance coverage protection of GLP-1 medication beneath Medicare, the government-funded insurance coverage program for folks 65 and older, and Medicaid, which supplies well being protection for sufferers with decrease incomes and other people with disabilities.
Though it won’t take impact earlier than Biden leaves workplace, the administration proposed a new rule that will outline weight problems as a persistent well being situation and canopy GLP-1 medication for people who find themselves overweight, even when they don’t have diabetes.
It’s unclear whether or not a Trump administration would approve the rule. President-elect Donald Trump’s decide to go the Department of Health and Human Services, anti-vaccine advocate and environmental lawyer Robert F. Kennedy Jr., has criticized GLP-1 medication, Reuters reported.
But Mehmet Oz, his nominee to run the Centers for Medicare and Medicaid Services, is a doctor and tv character who has endorsed GLP-1 drugs in a sponsored segment on his show and nonetheless promotes the medication on his web site, the Washington Post reported. Some have raised considerations a couple of potential battle of curiosity if CMS does ultimately cowl these medication beneath the management of Oz, additionally a former Pennsylvania Senate candidate.
But, on the identical time, personal insurers and a number of other state Medicaid plans have begun proscribing protection of the medication, citing their high costs.
Pennsylvania’s Medicaid plans spent $298 million on a number of GLP-1 medication between October 2023 and October 2024, about $106 per enrollee — the third-highest amount per beneficiary among states who cover GLP-1 drugs.
The state does limit its protection of the medication: To get hold of protection, Medicaid sufferers should even have Medicare and meet other health qualifications, together with having a body-mass index of at the least 30 and at the least one weight-related well being downside.
In the Senate listening to this fall, NBC reported, Novo Nordisk CEO Lars Fruergaard Jørgensen, whose firm sells Ozempic and Wegovy, stated he would think about decreasing the worth of medication if pharmacy profit managers, who contract with insurers to barter the medication insurance coverage will cowl, would nonetheless agree to incorporate it on their lists of accredited medicines for protection.
What IBX sufferers ought to do subsequent
IBX stated that sufferers ought to discuss to their docs about different methods to acquire GLP-1 medication if they’re dropping protection. Health financial savings accounts or versatile spending preparations could possibly cowl the medication, they stated.
And sufferers with medical situations like diabetes and coronary heart illness can nonetheless get protection for weight-loss medication by means of IBX.
“This change solely applies to weight reduction medication (e.g., GLP-1 and non-GLP-1 medication) when they’re prescribed solely for weight reduction and never for every other medical situations that the FDA has accredited them for,” the corporate stated in an announcement.
The firm additionally inspired sufferers with IBX plans to make use of “nonprescription choices” for weight reduction like behavioral well being, dietary counseling, reimbursement for fitness center memberships, and bariatric surgical procedure.
Staff writers Alison McCook and Harold Brubaker contributed to this text.
