In the United States, Wegovy is no longer just for weight loss.

The blockbuster drug is one of the few weight-loss treatments to soar in popularity last year, and it’s now also approved for heart health in the United States. But that may not lead to expanded insurance coverage for weekly magazines.injections from novo nordisk Similar treatments for obesity do not yet exist.

Some employers and other health insurance companies remain reluctant to cover Wegovy because of its high price tag of $1,350 per month, arguing that it can significantly strain their budgets. There are also other questions, such as how long the patient has actually been on treatment.

At least some insurance plans will take note of Wegovy’s new approval and begin evaluating whether to cover the treatment the next time they update their formularies, some insurance industry experts told CNBC. . That could mean tough decisions for insurance companies going forward, and Americans seeking treatment will likely survive on a patchwork of insurance systems.

“I think the more benefits that can be derived from weight loss drugs, the more pressure there will be to include them in prescriptions and include them in standard insurance plans,” said John Crable, senior vice president of Corporate Synergy. said. National insurance and employee benefits brokerage and consulting. “But my gut feeling is that it’s going to take longer to convince some insurance companies.”

Wegovy is a type of drug called GLP-1 that mimics hormones produced in the intestines to suppress appetite and help regulate blood sugar levels. Coverage for these treatments when used for weight loss purposes varies.

A Novo Nordisk spokesperson said in a statement that approximately 110 million adults in the United States are obese, and approximately 50 million of them have insurance coverage for weight loss drugs. The company is actively working with private insurance companies and employers to promote expanded coverage of these drugs and is advocating for the federal Medicare program to begin covering these drugs, a spokesperson said. added.

The Centers for Medicare and Medicaid Services said in an email that it is considering expanding FDA approval of Wegovy and will share additional information as needed.

The spokesperson added that the state’s Medicaid program will be required to cover Wegoby’s new cardiovascular uses. By law, Medicaid must cover nearly all FDA-approved drugs, but weight loss treatments are one of the few drugs that can be excluded from coverage. Currently, about one-fifth of state Medicaid programs cover his GLP-1 drug for weight loss.

Some of the country’s largest insurance companies are CVS Health Aetna, please cover those treatments.

But many employers don’t. An October survey of more than 200 companies by the International Foundation for Employee Benefit Plans (IFEBP) found that 76% of companies covered GLP-1 for diabetes treatment, compared to 76% of companies that covered GLP-1 for weight loss. Only 27% of companies guaranteed -1. Specifically, 13% of employers said they would consider compensation for weight loss.

The Food and Drug Administration approved Wegovy for weight management in 2021. In a landmark decision earlier this month, the Food and Drug Administration expanded its approval for Wegovy after it was found to reduce the risk of serious cardiovascular complications in adults with obesity and heart disease.

This decision was based on a five-year late-stage study that showed weekly injections of Wegovy reduced the overall risk of heart attack, stroke, and cardiovascular death by 20%.

This approval demonstrates that Wegovy and potentially similar drugs offer important downstream health benefits for severe conditions caused by excess body weight. Obesity increases the risk of several diseases, including diabetes, heart disease, and even some cancers.

It’s also fueled hesitancy among some insurance companies, which some health experts call “outdated” weight loss treatments that offer only cosmetic, not medical, benefits. It also calls into question the opinion.

“We’ve never seen anti-obesity drugs reduce the risk of heart attack or stroke,” said Dr. Jaime Armandos, a weight management and metabolism expert at the University of Texas Southwestern Medical Center in Dallas. ” he said. “What we’re getting is evidence that treating obesity is essentially life-saving, and I think that really changes the conversation.”

Some medical experts believe that applying Wegovy and other GLP-1s for weight loss purposes could potentially reduce future medical costs for plans and improve future health outcomes for patients. I am claiming.

Employers will “aggressively cover” these drugs if it helps reduce long-term costs, said Sean Gremminger, president and CEO of the National Federation of Health Care Purchasers. He said he was deaf. Members of this group represent private, public, nonprofit, union and Taft-Hartley organizations that spend more than $400 billion annually on health care.

But he said it will likely be years before employers have access to concrete data on the potential cost savings of covering these treatments.

Greminger added that employers are “a little less concerned” with how coverage of weight loss drugs will affect overall health care costs 10 years from now. They are focused on taking care of their current employees, some of whom will eventually leave the company.

Employers have other questions, including long-term data on GLP-1 for weight loss and patients discontinuing these drugs prematurely. It’s also unclear for some employers whether patients will have to stay on Wegovy for the rest of their lives or whether they can eventually taper off Wegovy, Gremminger said. Ta.

Because obesity and heart disease are chronic diseases, most patients will need to continue taking Wegovy along with their diet and exercise to maintain their health benefits. Nordisk said clinical trial data showed that people who took Wigovy regained weight when they stopped the drug, which is “not unexpected.”

“This supports the idea that obesity, like high blood pressure or high cholesterol, is a chronic disease that requires long-term management, and that most patients will continue to receive long-term treatment to continue to experience the benefits of their medications.” Novo said. Nordisk said in his statement:

But Greminger said the standard of care for long-term use of weight loss drugs is “in flux.”

Faced with the steep costs of covering Wegovy and similar drugs, North Carolina is cutting costs.

State employees will no longer have insurance coverage for the use of GLP-1 for weight loss early next month. The state health plan’s board of trustees voted in January to exclude these drugs from insurance coverage. The plan also continues to cover GLP-1 for diabetes, such as Novo Nordisk’s Ozempic, as well as some older obesity drugs.

North Carolina State Treasurer and Republican gubernatorial candidate Dale Falwell told CNBC that last week’s expansion of Wegobee’s approval doesn’t change anything.

“We’ve never doubted the effectiveness of the drug. We’ve always wondered how much we have to pay for it,” Falwell said. “Even if the use of this drug expands, the cost will remain the same.”

He said eliminating weight-loss drugs was not a decision the board wanted, but did so because the state’s plan was in a “stressed financial position” because of Wegobee. The treatment cost the state’s health care plan nearly $87 million last year, according to a state announcement in January. All told, his GLP-1 drug for weight loss cost him about $102 million for 2023.

Outside consultants predicted that if state plans continued to pay for these treatments, they would lose $1.5 billion by 2030. North Carolina also said that continuing coverage of GLP-1 for weight loss would reduce premiums for all 482,000 active employees and those who rely on the program, including those who are not taking the drug. It is estimated that this will double.

Falwell said the state is working with Novo Nordisk. Eli Lilly, Reaching a cost agreement with the manufacturer of a similar treatment, Zepbound. But he noted that companies were rejecting the country’s recommendations “at every turn.”

An Eli Lilly spokesperson said the company is committed to working with healthcare, government, and industry partners to “help those who could benefit from Zepbound access it.” , said there are still obstacles to that goal. The spokesperson added that insurance policy “has not kept up with the science”.

Novo Nordisk said in a statement that it asked Falwell and the state health plan to “put patients first” and reconsider their decision to exempt the weight loss drug.

According to a Novo Nordisk spokesperson, Novo Nordisk believes it is “irresponsible to deny insurance coverage to patients for an important and effective FDA-approved obesity treatment” and considers the potential cost implications. He said he will continue to work with state health planning officials to address concerns.

Both drug companies have launched a program to help patients pay for weight-loss treatments, regardless of whether they have commercial insurance coverage.

Novo Nordisk says its savings program allows uninsured patients to save up to $500 per 28-day supply of Wigoby. The company also said that about 80% of U.S. Wegovy patients who have commercial insurance for the drug pay less than $25 per month.

Ceci Connolly, CEO of Alliance of Community Health Plans, said increased competition in the weight-loss drug market could force both companies to cut costs for injectable treatments. The organization represents regional community-based health plans covering more than 18 million Americans across the United States.

Health plans may also become more aggressive about covering the convenient and potentially cheaper oral drugs that multiple drug companies are competing to develop. However, these cheaper options are probably still years away. This includes cheaper generic versions of existing GLP-1 and treatments from rival drug companies.

Julie Stich, IFEBP’s vice president of content, said the expanded approval will likely encourage more employers to consider applying Wegovy.

However, plans that decide to include Wegovy the next time they update their formulary may consider implementing certain requirements to control costs. These requirements are different for Wegovy’s two approved uses.

An October study by IFEBP found that most employers that cover GLP-1 for weight loss are already controlling costs.

Nearly one-third of companies said they use “step therapy,” which requires members to try other lower-cost drugs or weight loss methods before using GLP-1. Approximately 16% of employers used specific eligibility rules such as: For an employee to receive compensation, she must have a certain BMI (body mass index).

Other employers have adopted financial requirements, such as annual or lifetime spending caps on treatment. For example, Mayo Clinic’s employee health plan added a lifetime coverage limit of $20,000 for prescriptions for weight loss drugs filled after Jan. 1.

Meanwhile, some players in the insurance industry are exploring ways to help health plans control the cost of covering treatment costs.

last week, SignaPharmacy Benefits Administration announced that it will limit GLP-1 spending increases for employers and other health plans to a maximum of 15% annually. Currently, some of the company’s customers are seeing spending on these treatments increase by 40% to 50% annually.

As more healthcare companies pursue similar initiatives, their health insurers could become more aggressive in covering weight-loss drugs, “knowing that the risks are thus limited.” Yes, Stich said.