In the United States, Wegovy has expanded its application beyond weight loss alone.
This blockbuster medication, which has seen a surge in popularity along with a few other weight loss treatments in the past year, has now received approval for its efficacy in promoting heart health as well. However, this expanded approval may not immediately lead to broader insurance coverage for the weekly injection drug from Novo Nordisk and similar treatments for obesity.
Despite its new health benefits, some employers and health plans remain hesitant to cover Wegovy due to its substantial monthly cost of $1,350, which they fear could strain their budgets significantly. Moreover, there are lingering questions about the duration for which patients typically adhere to the treatment.
Several insurance industry experts have suggested that while some plans may take note of Wegovy’s new approval and consider including it in their coverage options during future formulary updates, the road to broader coverage may be challenging. This could result in a fragmented system of coverage for individuals seeking treatment.
John Crable, Senior Vice President of Corporate Synergies, believes that as the benefits of weight loss drugs continue to emerge, pressure will mount on insurers to incorporate them into their formularies and standard insurance plans. However, he anticipates that convincing some insurers may require further evidence.
Wegovy belongs to a category of drugs known as GLP-1s, which mimic a gut hormone to suppress appetite and regulate blood sugar. Coverage for these treatments specifically for weight loss varies.
According to a spokesperson for Novo Nordisk, approximately 50 million out of 110 million American adults living with obesity have insurance coverage for weight loss drugs. The company is actively engaging with private insurers and employers to advocate for broader coverage of these drugs and is also pushing for inclusion in the federal Medicare program.
The Centers for Medicare and Medicaid Services are reviewing the FDA’s expanded approval of Wegovy, with further information to follow. State Medicaid programs are mandated to cover Wegovy for its new cardiovascular application. While Medicaid must cover nearly all FDA-approved medications, weight loss treatments can be among the few excluded. Currently, approximately one in five state Medicaid programs cover GLP-1 drugs for weight loss.
Some major insurers, such as CVS Health’s Aetna, cover these treatments, but many employers do not. A survey by the International Foundation of Employee Benefit Plans (IFEBP) found that only 27% of over 200 surveyed companies provided coverage for GLP-1s for weight loss, compared to 76% for diabetes. However, a notable 13% of employers indicated they were contemplating coverage for weight loss treatments.
Downstream health effects
In 2021, Wegovy received approval from the Food and Drug Administration (FDA) for weight management. In a groundbreaking development earlier this month, the FDA expanded its approval following findings that Wegovy significantly reduces the risk of severe cardiovascular complications in adults diagnosed with obesity and heart disease.
This decision stems from a pivotal five-year, late-stage trial, revealing that weekly injections of Wegovy reduced the overall risk of heart attack, stroke, and cardiovascular-related mortality by 20%.
The expanded approval underscores the notable downstream health advantages of Wegovy, and potentially analogous medications, in addressing severe conditions triggered by excessive weight. Obesity is linked to heightened risks of various health issues, including diabetes, heart disease, and certain types of cancer.
Moreover, this decision challenges what some health professionals describe as an “outdated” narrative contributing to hesitancy among certain insurers: the notion that weight loss treatments solely provide cosmetic rather than medical benefits.
According to Dr. Jaime Almandoz, a specialist in weight management and metabolism at the University of Texas Southwestern Medical Center in Dallas, “We have not previously witnessed any anti-obesity medication diminish the risk of heart attack and stroke. What we now have is evidence demonstrating that addressing obesity can be life-saving, fundamentally altering the discourse.”