Debbie Halstead’s battle with obesity found a hopeful ally in Wegovy, but recent insurance changes threaten her progress.
Debbie Halstead from Cool Ridge, West Virginia, experienced a life-changing transformation with Wegovy. She lost 60 pounds, slashed her blood pressure by nearly 60 points, and found relief from debilitating knee arthritis. “Wegovy has been nothing short of a miracle for me,” Halstead shared. However, starting January 1, her Blue Cross Blue Shield insurance plan is altering coverage for GLP-1 drugs like Wegovy and Ozempic, skyrocketing her monthly cost from $25 to $713.
The Rising Cost of Hope
This isn’t just Halstead’s story. Across the nation, many working-age Americans are grappling with the soaring prices of weight-loss medications. Insurance companies are shifting these drugs to higher coverage tiers, making them nearly unaffordable for those who need them most.
- Current Cost: $25/month
- New Cost: $713/month
Such drastic increases leave patients like Halstead searching desperately for alternatives. “Even if I didn’t lose another pound, I’d take this drug as long as I could,” she lamented. “But at $700 a month, that’s not going to happen.”
Limited Insurance Coverage Hampers Access
The struggle doesn’t end with insurance hikes. Only about one-third of individuals prescribed GLP-1 drugs stick with them for a year or longer. These medications are intended for lifelong use, similar to blood pressure medications, and discontinuing them often leads to regaining lost weight.
Insurance Policies at a Glance
| Insurance Type | Coverage for Weight-Loss Drugs |
|---|---|
| Affordable Care Act Marketplaces | 1% coverage |
| Medicare | Limited to diabetes or heart conditions |
| Employer Plans | 44% cover obesity drugs in 2024 |
| State Government Plans | Some, but many like North Carolina have cut coverage |
Employer Strategies to Curb Costs
Employers are feeling the pinch as well. With GLP-1 drugs becoming more popular, prescription drug spending is the fastest-growing segment of employer health costs. In 2024, spending on these drugs increased by 7.7%, slightly down from 8.4% in 2023.
Most employers impose strict conditions for coverage, such as:
- Meeting BMI or weight-to-height ratio thresholds
- Obtaining prior authorization
- Consulting a dietician
Only 5% of companies allow employees to access these drugs without any restrictions, according to Mercer.
The Legislative Roadblock
The Biden administration proposed expanding coverage for obesity drugs to over 7 million Medicare and Medicaid enrollees by 2026. However, with President-elect Donald Trump taking office, the future of this initiative remains uncertain. The projected cost of this expansion is around $40 billion over a decade, a figure that has sparked debate among lawmakers.
U.S. Rep. Lloyd Doggett criticized the high prices, calling it “price gouging” and suggesting the federal government should authorize generic competitors despite patent protections.
Consumers Seek Cheaper Alternatives
Facing exorbitant costs, many turn to compounded drugs from pharmacies, though this route comes with its own set of challenges. Amanda Bonello from Marion, Iowa, opted for a compounded version of tirzepatide, paying $211 out of pocket for a month’s supply. While effective, she worries about the FDA’s stance on these alternatives, especially as drug shortages are declared over.
The Human Cost of Policy Changes
Dr. Angela Fitch, former president of the Obesity Medicine Association, emphasized that insurance coverage is the “biggest barrier” in the U.S. She argues that denying coverage for weight loss is not just unfair but could be considered malpractice given the current data supporting these medications.
Halstead, who works at the Veterans Health Administration, echoes this sentiment. She questions the long-term cost-effectiveness of denying access to weight-loss drugs that can reduce the need for other medications and medical interventions.
