Cryptic insurance rules hinder GLP-1 access for weight loss

Even the health insurance companies that cover Ozempic, Wegovy and other GLP-1 drugs for weight loss don't make it easy.

These glucagon-like peptide 1 agonists, which carry list prices up to $1,200 a month and must be taken indefinitely to maintain results, have exploded in popularity even though most insurers only cover them to treat diabetes.

Related: Insurers, PBMs restrict access to weight loss drugs as demand soars

A few companies, such as Highmark, do include GLP-1s for weight loss in the formularies for some plans. But there's a catch.

In order to qualify, patients must abide by step therapy requirements that are vague and put the onus on them and their doctors to figure out how to secure insurance coverage, policy documents show. For instance, members are told they must engage in diet and exercise programs, but insurers don't spell out what interventions are acceptable, how progress will be measured or whether those initial stages will be covered.

Among the 18 largest commercial insurers by membership, only Centene and Blue Cross Blue Shield of Michigan specify the types of exercise and diet programs they require, according to the Tufts Specialty Drug Evidence and Coverage Database.

“What does it mean to require patients to be in a comprehensive weight-management program? Is a gym membership enough? Is a subscription to Noom and being a member of a gym sufficient?" said James Chambers, a Tufts Medical Center professor who tracks coverage of high-cost therapies. "Or do you need to keep some sort of log that shows you attended the gym and adhered to counseling?”

Highmark Health’s requirements for Medicare Part D prescription drug plans, Kaiser Foundation Health Plan of the Northwest’s rules for exchange plans and UnitedHealthcare’s conditions for most self-insured employer plans require beneficiaries to enroll in unspecified diet, exercise, behavioral health or community-based programs, according to documents the consulting company Leverage provided to Modern Healthcare.

Employers and insurers have spent the last year decrying the impact GLP-1s have had on their finances. Some have tightened utilization management to contain costs while others, such as Blue Cross Blue Shield of Michigan, will stop covering them altogether.

Health insurance companies may simply be exercising caution because this class of drugs is novel, but their coverage limitations will provoke anxiety among patients and burden providers, said Robert Hartwig, director of the risk and uncertainty management program at the University of South Carolina Darla Moore School of Business.

"It's clearly going to cause confusion and frustration on the part of the provider given that many patients have come to believe that these drugs are a magic pill," Hartwig said.

Yet insurers are departing from the approaches they've taken when other high-cost therapies reached the market in recent years, Chambers said.

For instance, health insurance companies were explicit about what patients needed to do to get coverage for Amgen’s Repatha, also known as evolocumab, a biologic medicine the Food and Drug Administration approved to treat high blood pressure conditions in 2015, Chambers said. Like GLP-1s, this medication debuted with a large potential market and a hefty $14,000 annual price tag, he said.

Insurers generally required patients seeking Repatha coverage to have an established cardiovascular disease and take a high-intensity statin for at least three months without a reduction in blood cholesterol, Chambers said.

Insurers may be trying to balance their financial exposure against the risk of backlash if they refuse to pay for GLP-1s, said Rick Kes, a healthcare senior industry analyst at the consulting company RSM.

“Every organization that's managing this is probably like, ‘Well, we have got to be really careful of our public image here because we don't want to be seen as the bad guy,’” Kes said.

Tracy Zvenyach, director of policy strategy and alliance at the Obesity Action Coalition, sees another factor at work: bias against people with obesity. “Across payor types, it's oftentimes more coverage in name only and not true access to care,” she said. The Obesity Action Coalition is a patient advocacy group that receives financial support from drugmakers, device companies and providers.

UnitedHealthcare’s policy aligns with FDA guidelines and requires that physicians simply acknowledge that members are participating in a lifestyle modification program, a spokesperson for the UnitedHealth Group subsidiary wrote in an email. “Physicians are accustomed to this level of detail in a clinical policy,” the spokesperson wrote.

Kaiser’s weight management approach allows patients and physicians to collaborate to develop a personalized and comprehensive treatment plan, a spokesperson for the Oakland, California-based Kaiser Permanente subsidiary said in a statement.

Highmark did not respond to an interview request, but the company's top doctor recently offered some insight into the company's thinking about GLP-1s.

At the AHIP 2024 conference this month, Highmark Chief Medical Officer Dr. Timothy Law bemoaned the proliferation of GLP-1 prescriptions and said clinicians should be choosier about what patients get them so that insurers don't have to impose limitations. “I fear it's going to get pushed back to the insurance companies to be the bad guys,” he said June 12.

Centene did not respond to an interview request.

Blue Cross Blue Shield of Michigan spelled out what patients had to do to qualify for GLP-1 coverage for weight loss: Complete at least 150 minutes of exercise per week and reduce calorie consumption by 30%.

Nevertheless, Chief Medical Officer Dr. James Grant said the company decided to remove GLP-1s for weight loss from its fully insured group plan formularies next year after determining policyholders weren't staying on them long enough to see meaningful clinical benefits. The insurer is phasing out GLP-1 coverage and, starting in August, requiring current patients to obtain new prior authorizations from in-person clinician visits and to participate in a Teladoc weight-management program.

“I can't help but think that other payers are taking a hard look at these things,” Grant said.