Introduction
A new drug is changing the landscape of diabetes and obesity treatments forever. Its name is semaglutide, and its brands Ozempic and Wegovy. These two have been taking the world by storm with their blood sugar-relating and weight management benefits.
Though effective, they can burn a hole in your pocket if you buy them using your own money. But why do that if you have insurance?
In this article, we investigate whether your insurance covers Ozempic and Wegovy. When do they cover it, and when do they not cover it? The answers to all these and more when you read ahead.
What is semaglutide?
Before we dive into health insurance coverage for semaglutide, it’s important that we quickly define what it is. What is semaglutide and how exactly does it work?
Semaglutide belongs to a class of drugs, glucagon-like peptide-1 receptive agonists, or GLP-1 Ras. Now, in our gut is a hormone, GLP-1. After consuming food, GLP-1 triggers the pancreas to release insulin, a hormone that regulates blood sugar levels.
Semaglutide mimics GLP-1 and does the same. It also has an effect that slows down digestion (delays gastric emptying), making you feel fuller for longer. As a result, people’s appetites are weaker and they lose weight.
You can only purchase semaglutide products with a prescription. Ozempic and Rybelsus have FDA approval for treating type 2 diabetes while Wegovy is for weight loss. Despite these distinctions, doctors often prescribe Ozempic off-label for weight management.
Cost of semaglutide
To qualify for semaglutide, patients need a BMI of 27 with a weight-related condition or a BMI of 30 and above. After obtaining a prescription, purchasing semaglutide is straightforward.
According to a November 2024 report, semaglutide brands had the following pharmacy retail prices for one month’s supply:
- Ozempic: $830-870 (list price at $968.52)*
- Wegovy: $1,237-$1,340 (list price at $1,349.02)*
- Rybelsus: $848-$917 (list price at $968.52)*
Health insurance may cover these drugs if you have type 2 diabetes or if you have obesity. Meanwhile, semaglutide’s rival brands cost around $852* to $1,500* a month without insurance.
***Note: Prices are subject to change.
The US health insurance system
Most Americans access health insurance through employers, sharing premiums with their companies. Others buy individual or family health plans.
Drug coverage depends on the insurer’s formulary, a list of approved drugs. Coverage for Ozempic or Wegovy hinges on specific policies. Even with coverage, patients might still bear partial costs.
Although it may be possible for insurance to cover the drug, the coverage may not be 100%. There may be times when you may need to pay part of the cost.
Checking for semaglutide coverage
To confirm coverage for Ozempic or Wegovy, visit their websites. Complete a questionnaire, submit your details, and check your insurer. You can also review your health insurance policy documents or consult your insurance agent.
Non-coverage of semaglutide
Dr. Peminda Cabandugama explains that insurers often view obesity as cosmetic and not a chronic condition. High costs also deter coverage. For instance, monthly expenses easily exceed $1,000.
In 2023, only one in every four employers covered GLP-1 weight loss drugs. These employers, however, are tightening the criteria for their eligibility.
Another hindrance to coverage is a 2023 law that prevents Medicare from covering weight loss medications. Medicare is the US federal health insurance for citizens aged 65 or older.
Paradoxically, successful patients sometimes lose coverage. Dr. Dan Azagury noted insurers deny coverage when patients achieve a healthy BMI, countering treatment goals.
“We’ve had a patient who started at a BMI of 33, and now they’re at a normal BMI of 22, and the insurance is saying, ‘Well, now you have a normal BMI, so you’re not covered,’” shares Dr. Dan Azagury, medical director of the Stanford Bariatric and Metabolic Interdisciplinary Clinic.
Azagury believes it defeats the purpose of the drug, which is to help treat and maintain patients’ good health. He likened it to someone who succeeded in regulating their blood sugar levels by stopping their medication. However, he/she had to wait for the blood sugar levels to shoot up before using the same drug again.
A silver lining
There is a glimmer of hope, though. A growing number of companies are planning on incorporating weight loss drugs as part of their health plans in 2024.
Novo Nordisk and Eli Lilly are fast-tracking trials to demonstrate their medications’ health benefits beyond diabetes and obesity treatment. In this way, it will be easier for patients to get access to the expensive medicine that they need. Clinical trials are investigating whether drugs can lower the risk of heart attack, kidney disease, and other obesity-related chronic diseases.
In August 2023, Novo Nordisk found that semaglutide’s weight loss brand Wegovy cut the risk of cardiovascular problems by 20%.
In past trials, semaglutide has been successful in improving blood pressure and cholesterol—two risk factors for cardiovascular issues. However, the FDA needs standalone studies investigating heart health before they can conclude a drug has that benefit.
In October 2023, Novo Nordisk announced that semaglutide slowed the development of kidney disease in patients with type 2 diabetes.
Legislative promise
The 2021 Treat and Reduce Obesity Act proposed Medicare expansion to include weight loss drugs. Although the act received 154 co-sponsors, it did not receive a vote on the House floor before the term ended.
Nevertheless, the Congressional Budget Office has called for new research to support the use of weight loss drugs under Medicare. They are also keen to review the potential savings it could provide.
More savings in the long run
Research at the 2023 ObesityWeek conference found that human resources executives and benefits consultants thought positively of weight loss drugs. They agreed that these can help their employees enhance their overall quality of life. Moreover, they were interested in reviewing more information that would merit the approval of such high-cost coverages.
Economists point out that though weight loss drugs are costly, these save people money. They help prevent the risk of heart problems like cardiovascular deaths, heart attacks, and strokes.
A USC study estimated Medicare could save $175 billion in 10 years if it covered new GLP-1 weight loss drugs. US society as a whole could save as much as $1 trillion if all eligible Americans were treated with them.
Nevertheless, insurance companies are hesitant to cover weight loss drugs because their long-term effects and benefits are still unknown.
The problem with compounded semaglutide
High costs push some patients toward compounded semaglutide, which includes added ingredients. These compounded versions still contain the active ingredient but with the addition of other ingredients, such as vitamins.
The FDA has approved some drugstores to custom-mix variations of semaglutide and its competitor active ingredients tirzepatide and dulaglutide. However, these were affected by a supply issue in 2022. There have also been reports citing adverse effects from the compounded versions. Novo Nordisk and Eli Lilly have also reported impurities in the compounded medications.
Conclusion
Semaglutide is changing lives, with its proven efficacy in lowering blood sugar levels and promoting weight loss.
But affording it isn’t so easy. And insurance companies aren’t automatically covering it and similar drugs due to several reasons:
- They consider obesity as more of a cosmetic issue than a chronic disease, and
- A 2003 law prohibits Medicare from covering weight loss drugs.
Insurance companies also stop covering weight loss drugs once a patient successfully achieves his treatment goals, which is counter-intuitive.
On the bright side, more employers are considering coverage, as these could positively impact an employee’s quality of life.
Novo Nordisk and Eli Lilly are in a race to prove drugs’ health benefits beyond type 2 diabetes and obesity. For example, Ozempic slowed down the progression of kidney disease in patients with type 2 diabetes. Eli Lilly is also developing a new experimental weight loss drug called retratrutide. On average, it has helped people lose up to 24% of their body weight.
Once benefits outside of type 2 diabetes and obesity are proven, it will be easier for patients to be covered.
Amid the high cost of weight loss drugs, consumers are turning to compounded versions. Novo Nordisk and Eli Lilly warn against due to reports of adverse effects and impurities in the medication.
To check whether your insurance provider covers semaglutide and other similar weight-loss drugs, review your health insurance policy. Alternatively, the websites of Ozempic and Wegovy have pages dedicated to checking your products’ insurance coverage.
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