\’Obesity has a bad reputation\’: Why it\’s so hard for many to get new, expensive diet drugs that are covered by insurance

EMMAUS, Pa. — Doctors are finding that medications used for diabetic patients have been very effective for those struggling to lose weight. In fact, the FDA recently approved the same type of medications 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 them.

\”Rather than 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 so much more to this.\”

Schaffer, who lives in Emmaus with her husband and four children, says she has struggled with her weight throughout her life.

\”Always on the heavier side,\” he said. \”I never really understood why because I didn\’t necessarily eat badly, I was super active, into a lot of sports and stuff like that.\”

As time went on, checks revealed more.

\”Come to find out there was underlying stuff like PCOS,\” she said.

Polycystic ovary syndrome has symptoms such as weight gain, according to Johns Hopkins Medicine.

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

It means she\’s prediabetic. By her fourth child, she says her hormones had gone through the wringer.

\”I could literally run on the treadmill, 20 hours a day, and it doesn\’t just fall over, like some people,\” she said.

Schaffer recently learned about GLP-1 drugs, such as 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 drugs originally developed to treat diabetes,\” Biener said.

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

\”They don\’t have to use any or all other medicines to treat their diabetes,\” said Dr. Tim Law, Chief Medical Officer of Highmark, Inc. and a practicing physician in Kentucky. \”But then lo and behold, at the same time, they\’re losing, you know, 40 pounds in six months.\”

Doctors say the drugs, such as Ozempic and Mounjaro, are labeled for diabetics. But others, like Wegovy and Saxenda, were recently approved by the FDA specifically for weight loss.

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

\”If you have a car and the engine is broken, well yeah, you can push it around,\” he said. \”But if you don\’t fix the engine, it won\’t work.\”

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

\”Monthly injections that can cost over $1,000 a month,\” Biener said. \”So when you\’re talking about $12,000 a year for drug maintenance.\”

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

\”I faxed all my doctors, you know, all the information about my PCOS and my weight gain and everything,\” she said. \”And it\’s like, they, they were like, \’Well, too bad.\’ You know, they don\’t care.\”

Some patients report having had luck with coupons, such as the one for Ozempicor GoodRX.

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

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

That\’s why these new drugs could be a game changer. So why are there so many checkpoints?

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

Biener says that because the drugs are so new and complex, they\’re currently only prescribed by a doctor.

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

And these high prices are why, experts say, it may be so difficult to cover it with your insurance: because the companies have to pay those large sums.

\”Unfortunately, obesity has a bad reputation, right,\” Dr. Law said. \”If you have a small business with, you know, 50 employees and you\’re trying to get insurance for everyone, maybe that\’s one of the things you eliminate.\”

Law says about 88 percent of the GLP-1 prescriptions that come in through his company are for diabetes. Only 12 percent is for weight loss.

\”But you have to meet certain criteria, you know, your BMI has to be above a certain level in that sort of thing,\” she said.

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

“Make it more difficult or limit where they will cover,” Biener said. \”You have to have other comorbidities, say diabetes, or coronary heart disease or something like that.\”

Experts say that with the novelty and demand for the drugs right now, there isn\’t much 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 still have more supply chain problems than we do.\”

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