When Tim Norfleet heard the Ohio Department of Education would pay for its workers to use anti-obesity drugs, he knew he wanted to sign up.
Norfleet, 61, a federal programs specialist, said he had been mulling undergoing weight loss surgery after gaining 50 pounds since the start of the COVID-19 pandemic. But using a drug, combined with exercise and diet changes, seemed preferable to surgery.
His company's pharmacy benefit manager, UnitedHealth Group’s OptumRx, in August agreed to cover the cost of Wegovy. But rising demand created a shortage of the drug, which meant Norfleet was unable to fill his prescription until January. After six months, OptumRx required Norfleet to receive a second prior authorization to access the drug. He was denied, further delaying his treatment.
"The representative I spoke to could not or would not provide me with a reason why it was denied,” Norfleet said. “They just said they were not going to give me more medication.”
Payers have taken a cautious approach to handling rising demand for the pricey new class of drugs known as glucagon-like peptide agnostics, or GLP-1s. They include Novo Nordisk’s Wegovy and Saxenda, both approved for weight loss, as well as the diabetes drug Ozempic.
The drugs can cost more than $13,600 per patient per year, and the potential market is large: Approximately 142 million adults nationwide meet the Food and Drug Administration’s prescription criteria, according to the Institute for Clinical and Economic Review, a nonprofit that reviews the cost-effectiveness of medical treatments. These individuals either are obese with a body mass index of at least 30, or have a BMI of at least 27 and a pre-existing condition, such as diabetes.
The drug category has sparked familiar finger-pointing across the prescription supply chain. Payers say they want to provide patients access to GLP-1s, but can't because of high costs set by manufacturers. Drugmakers blame PBMs for the lack of coverage and high out-of-pocket expense. Both sides hope to sidestep the squabbling by downplaying the drugs' clinical benefit and painting GLP-1s as "lifestyle" or vanity medications and shift the cost burden to consumers, said Antonio Ciaccia, CEO of drug pricing research firm 46brooklyn Research and president of 3 Axis Advisors.
“Insurers understand that this is about to be a tidal wave,” Ciaccia said. “But I think [insurers] also understand that, for many patients, they'll be willing to pay for this stuff no matter what, regardless of whether it's covered. It's a great opportunity for insurers to shirk their traditional responsibility of coverage with the argument that, ‘Hey, this is just a vanity med.’”
The majority of insurers are responding to the rising demand by imposing restrictions beyond the Food and Drug Administration’s label, allowing only the most obese patients access to the drug, requiring patients to enroll and complete diet and exercise programs, or test and fail lower-cost drugs before agreeing to pay for Wegovy, according to an analysis of insurer coverage policies by the Specialty Drug Evidence and Coverage Database at Tufts Medical Center.