When Insurance Won’t Cover Your Meds
Justin Bronder thought he knew exactly what he needed.
Bronder, 57, of San Jose, CA, had struggled with his weight for most of his adult life. His job in artificial intelligence took him all over the world, but the long hours and constant travel led to steady weight gain. At his heaviest – 265 pounds – his BMI fell squarely into the obese category. His blood work started to reflect this with higher blood pressure and blood sugar levels.
He had tried lots of diets including keto and intermittent fasting, but even when he managed to lose some weight, he gained it all back.
Then, about 5 months ago, Bronder ran across some research about a weight loss drug called semaglutide (Wegovy). The drug mimics a naturally occurring hormone called GLP-1 that lessens cravings, increases satiation, and slows digestion so that you feel full for longer.
Clinical trials on Wegovy including a double-blind, placebo-controlled study (the scientific gold standard) show an average 15% weight loss. This is quite an effect, considering that scientists have long known that weight loss of just 5% to 10% may stop or slow the onset of diabetes and help improve blood pressure, cholesterol, and blood sugar levels.
Bronder seemed like a perfect candidate for the drug. And his doctor agreed.
But there was a problem. Many insurance companies were refusing to cover the drug. Some insurers call it a “lifestyle” or “vanity” drug – a curious way to refer to a drug that treats a condition (obesity) that is a risk factor for diabetes, heart disease, high blood pressure, arthritis, dementia, and depression, among other conditions.
Bronder is a case in point. He was prediabetic, according to his doctor, a problem almost certainly caused or worsened by his weight. In fact, it was this condition that qualified him for a medication (Ozempic) identical to Wegovy, but in a smaller dose (1 milligram vs 2.4 milligrams for Wegovy).
Ironically, the very drug that could have helped prevent his prediabetes would likely not have been covered until he actually developed the condition.
Bronder knew he was one of the lucky ones. Social media message boards and chat groups were filled with stories of frustration, many of which ended in denied coverage. And without insurance coverage, a cost of $1,000 to $1,600 a month puts these drugs out of reach for the great majority of Americans.
“It seemed inconsistent. Some people were able to get it covered by their insurance, others weren’t. Or they got it covered and then their insurance later denied it,” he says.
“I think it’s terribly unfair because your health shouldn’t depend on whether you’re rich or poor,” he says.
Effectiveness Seems Beside the Point
“It’s been extremely frustrating because [Wegovy] is the most effective obesity medication we’ve ever seen and there are many insurers who won’t cover it at all,” says Katherine H. Saunders, MD, an assistant professor of clinical medicine at Weill Cornell Medicine in New York City.
“We’re trying to treat as many patients as we can, but we’ve been really limited by insurance coverage,” she says.
But Wegovy isn’t the first effective medication that insurance companies have refused to cover and it’s unlikely to be the last, says Geoffrey Joyce, PhD, director of health policy at the University of Southern California’s Schaeffer Center for Health Policy and Economics.
“We could have eradicated hepatitis C with the medication Sovaldi,” says Joyce. “But who could afford the original price tag of $84,000 for the treatment?”
The problem with Sovaldi wasn’t the cost of the drug so much as the market size, says Joyce. About 5 million people with hep C could have benefited from Sovaldi. Insurers were wary of taking that on all at once, says Joyce.
“We have plenty of high-cost drugs for things like cancer and MS that are covered because the patient population isn’t that big so insurers can absorb the cost in premiums, but when the market is huge like this, it’s too much for any insurer to swallow.”
The possible market for Wegovy is closer to 100 million – maybe more.
Still, why not cover it? Wouldn’t it be easier – and cheaper – to treat obesity before it leads to more serious conditions like diabetes, heart disease, and high blood pressure?
Perhaps, says Joyce. But insurance companies are in a difficult position. In the short term, it may be impossible to suddenly cover a market of 100 million people or more without going out of business. So insurers kick the can down the road, even when the expense over the long term may be higher, Joyce says.
Signs of Hope
Wegovy is a relatively new medication, approved by the FDA in June 2021. The good news about its effectiveness is still filtering down to health care providers and insurance companies. As it does, insurers may start to loosen the reins, Joyce says.
At first, insurers may restrict access only to patients who have a very high BMI or who have tried other medications unsuccessfully. And some restrictions will likely continue – as with Sovaldi (the hep C drug) – until competition drives down prices and generic drugs are allowed into the market, says Joyce. (The effective patent is around 8-12 years on most branded drugs).
But if the drug truly works, it will usually make its way to the mainstream, he says. If you can’t get coverage at first, keep asking questions. In many cases, there are nonprofit organizations that will help people in need pay for medications. Or there may be a similar drug that your insurer will cover instead.
As for Bronder, he has lost 52 pounds on Ozempic and he can’t believe how good he feels, eating simple, low-carbohydrate meals with a protein and a vegetable. He likes looking trimmer, but his recent blood work shows that the drug is about way more than physical appearance. His cholesterol, blood pressure, and blood sugar have returned to a normal range.
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