How To Access Groundbreaking GLP-1 Weight Loss Drugs
- GLP-1 receptor agonists (GLP-1 RAs) weight loss drugs, like Ozempic and Wegovy, have become household names.
- Originally developed to help people with type 2 diabetes control blood sugar, these drugs have shown an incredible ability to help many people lose weight.
- However, cost can be a barrier for many — and many insurers will not cover the drugs unless patients meet very specific requirements.
- There are steps patients can take to gain access to these drugs — including making use of manufacturer savings programs, getting prior authorization, and appealing denied claims.
While the health benefits can be impressive, many patients face a pressing hurdle: cost.
Read MoreWhy Are These Drugs So Expensive?
There are several reasons that GLP-1 RA medications are currently expensive. One is research: GLP-1 medications are the result of extensive research, making them more expensive than many older drugs. Some GLP-1s have been around for diabetes treatment for years, but their use for weight loss is relatively new and in high demand.Several companies manufacture GLP-1 drugs, but tight supply chains and the specialized nature of these injections can limit how quickly new versions reach the market. Less competition often means higher prices.
These medications have also become very popular. More physicians are recommending them, and more patients are eager to try them — especially after seeing dramatic weight loss results in friends or on social media. That surge in demand can drive list prices up.
There’s also the issue of what GLP-1 medications are currently approved for. Those who wish to use the medications to lose weight and reduce their cancer risk may find their insurance does not cover the preventative measure.
“I think that in the future we will use GLP-1s for, potentially, obesity prevention and thus decrease the exposure of patients who are at risk for cancer to these inflammatory hormones that can increase their cancer risk,” Dr. Holly Lofton, director of the Medical Weight Management Program at NYU Langone Health in Manhattan, tells SurvivorNet.
“What would need to change in order for this to happen would be the expansion of the indication for GLP-1 agonists. Currently, they are approved to treat overweight and obesity, and not exactly to prevent,” she adds.
How Much Could You Pay Out of Pocket?
The out-of-pocket cost for a brand-name GLP-1 can range from $1,000 to $2,000 per month if you don’t have insurance coverage — or if your insurer doesn’t cover weight loss prescriptions. That’s a steep price for most individuals, and it’s a cost you might have to bear indefinitely if you plan to stay on the medication long term.
Compounded GLP-1 Medications
You might find ads for “compounded” versions of semaglutide or tirzepatide at a fraction of the price — some starting as low as $165 a month. Compounded drugs are made by pharmacies that modify the original medication (for example, by changing the formulation or combining different ingredients). However, these compounded versions are not approved by the Food and Drug Administration (FDA), which means their safety and effectiveness are not guaranteed to match the original brands. It’s wise to discuss the potential risks with a healthcare provider before considering these options.
The FDA has received reports of adverse events related to compounded versions of semaglutide and tirzepatide. However, federal law does not require state-licensed pharmacies that are not outsourcing facilities to submit adverse events to FDA so it is likely that adverse events from compounded versions of these drugs are underreported.
As of November 30, 2024, FDA has received:
- More than 392 reports of adverse events with compounded semaglutide
- More than 215 reports of adverse events with compounded tirzepatide
Understanding Insurance Coverage
A recent look at Affordable Care Act (ACA) Marketplace plans shows just 1% cover Wegovy for weight loss.
By contrast, 82% cover Ozempic, but usually only when prescribed for diabetes management, not weight loss. Even if your plan covers a GLP-1, it may require prior authorization, quantity limits, or other rules designed to manage costs.
Employer-Sponsored Plans
If you have insurance through an employer, coverage might be slightly more generous — particularly if employers see offering weight loss benefits as a way to attract and retain workers.
Still, many employer plans mirror the same utilization management techniques used on the Marketplace, requiring medical necessity documents or proof of ongoing health issues before approving coverage.
Medicare and Medicaid
Medicare generally does not cover weight loss prescriptions, though it may cover these drugs for diabetes or other specific indications. Medicaid coverage varies by state. Some states offer coverage for certain weight loss medications if you meet specific criteria, sometimes at extremely low copays (like $3 or less for Wegovy).
Check your plan’s pharmacy benefit documents or contact your insurance provider directly. Even if weight loss drugs aren’t typically covered, exceptions may exist for patients whose obesity poses serious health risks.
Tackling the High Costs: Practical Strategies
1. Check Manufacturer Savings Programs
Major drugmakers like Novo Nordisk (producer of Ozempic and Wegovy) and Eli Lilly (producer of Mounjaro and Zepbound) offer savings cards or rebates for patients with commercial insurance. Depending on the program, you could save hundreds of dollars per month or reduce your copay to as little as $0 to $25.
These programs often have expiration dates (e.g., 24 months), and they can change suddenly. That means you may see an unexpected jump in costs down the line.
2. Use Prior Authorization Effectively
If your plan requires prior authorization, your doctor may need to submit notes explaining why you need a GLP-1 medication.
Provide detailed information about your obesity-related health conditions, such as high blood pressure or diabetes. A thorough application can increase the likelihood of approval.
3. Consider Appealing a Denial
If your insurer denies coverage for a GLP-1 drug, you generally have the right to appeal.
Ask your healthcare provider to supply any additional medical evidence, like lab results or weight-related health complications, that could support the appeal.
4. Think About Long-Term Budgeting
Given that many people remain on GLP-1s for a year or more — some indefinitely — it’s crucial to factor in how you’ll handle these costs over time.
If you’re relying on a short-term savings card or coupon, investigate alternative options well before it expires.
5. Look Into Patient Assistance Foundations
Some nonprofit organizations or patient advocacy groups help with medication costs for people who meet certain income requirements. While it can be challenging to qualify, it’s an avenue worth exploring if you’re struggling financially.
The Bottom Line
GLP-1 medications can be life-changing for some people, but the financial hurdles can be just as daunting as the health issues they aim to address. Limited insurance coverage, high list prices, and strict approvals can all stand in the way. Yet there are pathways to make these treatments more affordable — through insurance checks, manufacturer discounts, or working closely with a healthcare provider.
Questions To Ask Your Doctor
- Am I a candidate for a GLP-1 receptor agonist?
- What if my insurance does not cover the drug?
- Can you advocate on my behalf for coverage?
- What’s the process like to get started on the drug?
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