As demand surges for GLP-1 therapies, insurers are pulling back on coverage, according to new data from obesity care provider Found.
The company analyzed GLP-1 benefits and access for its patient population and found that currently 69% do not have coverage for this class of drugs to treat diabetes or for weight loss, a significant decline in coverage in the past seven months. The findings, which were provided exclusively to Fierce Healthcare, track with national trends in coverage for these products, the Found team said.
Coverage for GLP-1 drugs has decreased by 50% since December 2022, according to the analysis. Nearly 70% of insurance plans included in the study did not indicate coverage for GLP-1s either for obesity or diabetes treatment.
Sarah Jones Simmer, CEO of Found, said in an interview with Fierce Healthcare that the trends are likely the result of irresponsible prescribing for recreational reasons causing the pendulum to swing "all the way in the other direction," and it's leading to patients who have genuine medical need struggling to access these therapies.
"Holding that high bar for prescribing is what’s going to win this game in the long run," she said. "You have to think about this as chronic disease management, not responding to a TikTok trend."
Rekha Kumar, M.D., Found's chief medical officer and a specialist in obesity medicine, said that the increased attention and demand for drugs like Ozempic and Wegovy are leading payers to look far more closely at prescriptions and deny coverage more frequently. And it's putting doctors in a difficult position with their patients, she said.
"The part that concerns me the most is how insurance companies and employers are reacting to the inappropriate use," she said.
The study found that GLP-1 coverage for patients declined from 27% in December 2022 to just 12% in June 2023.
Found offers a medication-assisted treatment program for obesity that includes GLP-1s as a therapy when appropriate but does not lean on them exclusively. Kumar said that endocrinologists and others trained in treating obese patients play a critical role in determining what care pathway is best for them.
For example, she said she recently treated a patient who had been taking Ozempic as an off-label prescription from a different doctor for several months and was not seeing results in terms of weight loss or appetite control. The cost for those prescriptions was still felt in the system, even though it was not effective, which is why Found offers multiple medication pathways to patients as alternatives.
Jones Simmer said that insurers and employers are taking multiple approaches to address this issue, from leaning more closely on their pharmacy benefit managers to outright dropping coverage options. As demand continues to grow, insurers' "tolerance" for the cost of these drugs is waning, she said.
She said the Found team did hesitate initially to release the data, as they don't want to discourage patients struggling with obesity or diabetes from seeking care, including potential GLP-1 prescriptions if that's the best fit for them. However, continuing to track how employers and payers are navigating the complex environment around these drugs is key to ensuring they can reach the right patients.
"Candidly we debated sharing this information because I think there’s so much moving around as it relates to coverage," she said, "but I think it’s important for people to understand just how much the dynamics have changed."