Store bins at the corner drugstore are bursting with Halloween candy, but those trying to shed a few pounds are finding mostly bare shelves when it comes to the costly blockbuster weight-loss drugs created initially to fight diabetes.
A nationwide collision over supply, demand, and lack of insurance coverage for the newly rebranded drugs has placed many patients in a bind of having to pay upwards of $15,000 a year out-of-pocket, or forgo the treatments altogether.
Wegovy, a highly popular weekly injection weight loss drug that regulates appetite, costs about $1,300 a month per patient. Most employer insurance plans don’t cover it, and the drug shortage predicament is a fairly new phenomena. But the active ingredient of Wegovy, semaglutide, has been around since 2012 when it was first developed by Denmark-based Novo Nordisk and brought to market in 2017 as Ozempic to treat diabetes.
Back then, “there wasn’t an insurance or supply issue — I don’t even remember needing to prior-authorize it,” said Dr. Joe Feuerstein, an integrative medicine specialist based in Stamford. That all changed when Ozempic got approved under the name Wegovy for weight loss. “Insurance is obviously going to want some kind of barrier to restrict this because they can’t afford … for almost everybody they insure to be on this medicine.”
Novo Nordisk officials declined to be interviewed for this story and instead submitted a written statement.
“Novo Nordisk believes the most effective way for the millions of Americans who need anti-obesity medicines to be able to access and afford them is to ensure these medicines are covered by government and commercial insurance plans,” wrote Allison Schneider, director of media relations for the company. She said that Novo Nordisk is working with private insurers to provide coverage for patients who want access, but can’t afford it.
According to the U.S. Centers for Disease Control and Prevention, about 11 percent of the U.S. population has diabetes and about 42 percent are obese. As a result, more than half of Americans could likely seek treatment with semaglutide or another drug of its class.
The drug works primarily by promoting the sensation of “satiety,” the feeling of being full after eating, health care officials say. This helps reduce appetite and promotes insulin production which, in turn, reduces a person’s weight and blood sugar.
Susan Halpin, executive director of the Connecticut Association of Health Plans, said insurance carriers were “closely monitoring the emerging science.” She added that “weight-loss drugs are not required coverage in Connecticut … but some employers have chosen to provide such coverage.”
The industry would be looking at cost-benefit analysis to determine if coverage was worthwhile, in terms of overall improved health status, she said, pointing to an early, industry analysis by disease forecasting company Airaffinity that found it would cost about $1.1 million of treatment with semaglutide to prevent one heart attack, stroke or cardiovascular death. Airaffinity’s analysis has not been peer-reviewed, however.
In an email exchange with CT Insider, officials with the American Diabetes Association expressed concerns about barriers to care for people with obesity and diabetes. “GLP agonists, like semaglutide, have been linked not only to improved diabetes management and weight loss, but also to reductions in serious heart disease,” wrote Dr. Robert Gabbay, the ADA’s chief medical officer. “Overall, we want to ensure that all people with medical conditions who could benefit from these medications have access to them.”
It wasn’t always hard to get
Endocrinologists and others who work closely with diabetic patients to manage their condition realized fairly quickly that semaglutide drugs usually resulted in weight loss, and prescribed them for that purpose.
“Prior to 2023, that kind of off-label prescribing was done very easily and approved by commercial insurers and Medicare,” said Dr. Maria Cecilia Asnis, director of the Stamford Health medical weight loss program.
But when Novo Nordisk won approval for Wegovy to be used for weight loss in 2021, interest skyrocketed. The drug made major waves on social media, especially in the “self care” and “lifestyle” niches. Insurers, suddenly on the hook for far more courses of semaglutide than before, balked. Both private insurers and Medicaid “tamped down if not eliminated coverage” for off-label Ozempic, Asnis said.
“If there’s a drug that costs over $1,200 a month, it’s difficult to argue against payer if they say this drug is not approved for this patient because they don’t have diabetes,” said Dr. Wajahat Mehal, Yale New Haven Health director of metabolic health and weight loss. “Many insurance companies right off the bat exclude all weight loss drugs.”
Employers consider coverage
A survey of employment-based health plans by Accolade, a personalized health care service, found that only 30% of employers covered weight loss drugs, but that over half of employers surveyed were open to the possibility. The primary barriers, Accolade found, were cost and uncertainty.
A Kaiser Family Foundation survey found that 80% of adults support insurance companies covering weight loss drugs for people who are overweight or obese.
The largest employment-based health plan in Connecticut for state employees, retirees and their families does cover Wegovy for weight loss. Connecticut Comptroller Sean Scanlon told CT Insider that, overall, the response to covering Wegovy had been positive.
“I don’t want to take these drugs away from everybody,” said Scanlon. “But I want to make sure we’re spending this money wisely.”
He explained that historically Connecticut had covered semaglutide for diabetes. Rather than just drop coverage, Scanlon said the state partnered with Intellihealth, a Connecticut-based company that offers a clinical lifestyle management program.
“There’s a lot of data out there that shows if you pair lifestyle changes, specific goals and specialty care” with these drugs, “it’s going to make a bigger, more positive impact,” he said.
So far about 1,000 people under state insurance plans have signed up for both Wegovy and the Intellihealth program. Scanlon said he intends to revisit the partnership in the spring to see if it’s working for everybody. If it’s successful, the approach might be a model for the rest of the state, he said.
This paired approach is something that many doctors in the diabetes and weight loss clinics recommend. Weight is governed by complex, overlapping factors including diet, activity, prescription drugs, genetics, mental health, and other illnesses. Using a drug like semaglutide alone is not a longterm solution.
“I like this drug because it augments the lifestyle,” Feuerstein said. “And I think if you just take these drugs and do nothing else, you’re not going to get anywhere.”
