The makers of the new class of weight loss drugs Ozempic, Wegovy, and Mounjaro are working to prove their popular drugs have enough health benefits for insurance carriers to cover their high price tags.
It could mean a big shift in costs in the future. Right now, many insurance companies do not cover these drugs or have strict conditions on coverage because of their high costs.
It’s a struggle that has left many Americans unable to access the drugs.
What are the new “weight loss” drugs?
The most popular drugs on the market for weight loss are Ozempic, Wegovy, and Mounjaro. Ozempic and Mounjaro are approved by the FDA to treat type 2 diabetes. These drugs are not approved to treat obesity but are currently being prescribed for it. Wegovy is the only version of these drugs that has been approved for chronic weight management.
Once prescribed, patients take the drugs through subcutaneous (under the skin) injection. These drugs have become increasingly popular because of how effective they are in aiding weight loss.
Are these drugs covered by insurance?
Many health insurance plans do not provide coverage for the medication Ozempic and Mounjaro when it is used for weight loss. This is because they are currently only approved by the FDA for the treatment of type 2 diabetes. Although some healthcare providers may prescribe the drugs off-label for weight management, it is unlikely that insurance companies will cover the cost of medication for this purpose.
Insurance companies that do provide coverage for weight loss drugs often require additional documentation to see if the patient qualifies for coverage. That may include test results or assessments by physicians. Requirements for coverage from the insurance company can change at any time.
Providers across the country have complained of changing standards that have made it more difficult for patients to keep coverage.
How do Ozempic, Wegovy, and Mounjaro work?
Ozempic and Wegovy both use the ingredient semaglutide. It stimulates the GLP-1 receptor, which makes people feel less hungry and slows the emptying of the stomach. Studies show that the drugs help people:
- Lower blood sugar
- Reduce the risk of heart failure
- Achieve average weight loss of about 15%
- Experience less appetite or cravings
People using the drug also experience side effects like nausea, abdominal pain, low blood sugar, and other stomach issues.
Mounjaro uses the ingredient tripeptide, It is a glucose-dependent insulinotropic polypeptide receptor and GLP-1 receptor agonist. In essence, it mimics the hormones the intestines naturally produce so that a person feels fuller for longer. It also slows digestion.
People using Mounjaro often experience the same improvement and side effects as Ozempic and Wegovy. Again, Wegovy is the only one of these drugs approved by the FDA for weight management alone. Ozempic and Mounjaro are approved as drugs to treat type 2 Diabetes.
Are these drugs covered on my ClaimLinx plan?
All plans ClaimLinx administers are custom to the company so always check with your plan administrator if you have questions about benefits. However, as a general rule, the MERP Plans ClaimLinx administers follow the coverages outlined in the primary insurance plan.
That means members can receive coverage for these drugs if they meet the standard the insurance company requires. That includes limits on coverage for people who do not have type 2 diabetes.
What are the costs of these drugs?
Ozempic, which is intended for those with type 2 diabetes, comes in pre-filled pens that hold multiple doses. If you are eligible for insurance coverage, you can get Ozempic for as little as $25 per month. However, without insurance, the average cost of Ozempic is approximately $892.06 per month.
Mounjaro, though it has a different ingredient, carries a similar price tag without insurance. This medication is also intended for those with type 2 diabetes. It can cost up to $1,069.08 per month if it’s not covered by insurance.
Wegovy, when it is prescribed for weight loss, is a weekly medication that works best when taken along with regular exercise and a low-calorie diet. The cost of Wegovy can be more than $1,300 per month without insurance.
Why do insurance companies deny coverage?
Coverage for these drugs is likely to change drastically in the coming years. Insurance companies have cracked down on coverage recently because of the high sticker price of the drugs.
According to two surveys conducted in October 2023 by the International Foundation of Employee Benefit Plans and the employee research firm Savanta, only 25% of employers covered GLP-1 drugs for weight loss in 2023.
High demand compounded with high cost has forced many companies and/or insurance carriers to limit coverage. Currently, insurance companies point to the fact that Ozempic and Mounjaro are only approved for type 2 diabetes as the major reason for denying coverage
However, coverage decisions are a more complex picture and are subject to change in the future. If the drugs are proven to reduce health risks or expensive health events, coverage may change. That is why the drug makers are in a rush to prove the wider uses of the drugs.