IBX will no longer cover drugs like Ozempic when they are prescribed solely for weight loss

Dec. 24—Starting in the new year, Independence Blue Cross, the region's largest health insurer, will no longer cover anti-obesity drugs like Ozempic and Wegovy when they're prescribed solely for weight loss.

The drugs' high costs have caused an increase in premiums that "affect all members, whether they utilize weight loss drugs or not," IBX said in a statement Tuesday.

The decision was posted on IBX's website in November and drew local press coverage this week. The company noted that several other insurers have made similar decisions in recent months when it announced the change last month.

"The cost of these drugs in the U.S. is almost 10 times more than other parts of the world and that has made it extremely challenging to be able to continue to provide coverage to everyone who wants to lose weight or can benefit from the drugs," the company said.

Without insurance, the drugs can cost $1,000 or more a month. Wegovy, for example, costs as low as $92 a month in the United Kingdom but $1,349 in the United States, NBC reported.

The high prices in the United States spurred a Senate hearing this fall that drew attention to the nation's complex drug pricing system. A relative lack of market competition, exclusive patents, and the negotiations between insurers, drug companies, and the benefit managers involved as middlemen have all received scrutiny and can contribute to higher drug prices.

IBX's decision applies to all drugs prescribed only to help a patient to lose weight and not to treat any other conditions. The rule takes effect on Jan. 1.

That includes a class of extremely popular drugs known as GLP-1 receptor agonists, now prescribed to about one in eight American adults. They mimic the effects of the GLP-1 hormone to regulate blood sugar levels. Some are approved by the Food and Drug Administration only to treat diabetes or cardiovascular disease, but others are approved to encourage weight loss as well.

Many doctors have prescribed them to patients who have struggled to lose weight and say such drugs have changed their lives. In areas where insurers previously have dropped coverage, many patients and physicians have criticized that decision as shortsighted. They say it cuts off patients from medications that often improve their health more effectively than other drugs or lifestyle changes alone.

The American Diabetes Association has warned that abruptly stopping such medications could cause patients to gain weight again and increase their risk for diabetes and heart conditions, the New York Times reported.

Still, other patients have raised concerns about the drugs' potentially harmful effects: In Philadelphia, a federal court case is underway against major GLP-1 drug manufacturers, brought by patients who say the companies did not adequately warn them of serious side effects.

Exorbitant prices

In its final weeks in the White House, President Joe Biden's administration last month signaled support for expanded insurance coverage of GLP-1 drugs under Medicare, the government-funded insurance program for people 65 and older, and Medicaid, which provides health coverage for patients with lower incomes and people with disabilities.

Though it will not take effect before Biden leaves office, the administration proposed a new rule that would define obesity as a chronic health condition and cover GLP-1 drugs for people who are obese, even if they don't have diabetes.

It's unclear whether a Trump administration would approve the rule. President-elect Donald Trump's pick to head the Department of Health and Human Services, anti-vaccine advocate and environmental lawyer Robert F. Kennedy Jr., has criticized GLP-1 drugs, Reuters reported.

But Mehmet Oz, his nominee to run the Centers for Medicare and Medicaid Services, is a physician and television personality who has endorsed GLP-1 drugs in a sponsored segment on his show and still promotes the drugs on his website, the Washington Post reported. Some have raised concerns about a potential conflict of interest if CMS does eventually cover these drugs under the leadership of Oz, also a former Pennsylvania Senate candidate.

But, at the same time, private insurers and several state Medicaid plans have begun restricting coverage of the drugs, citing their high costs.

Pennsylvania's Medicaid plans spent $298 million on several GLP-1 drugs between October 2023 and October 2024, about $106 per enrollee — the third-highest amount per beneficiary among states who cover GLP-1 drugs.

The state does restrict its coverage of the drugs: To obtain coverage, Medicaid patients must also have Medicare and meet other health qualifications, including having a body-mass index of at least 30 and at least one weight-related health problem.

In the Senate hearing this fall, NBC reported, Novo Nordisk CEO Lars Fruergaard Jørgensen, whose company sells Ozempic and Wegovy, said he would consider lowering the price of drugs if pharmacy benefit managers, who contract with insurers to negotiate the drugs insurance plans will cover, would still agree to include it on their lists of approved medications for coverage.

What IBX patients should do next

IBX said that patients should talk to their doctors about other ways to obtain GLP-1 drugs if they are losing coverage. Health savings accounts or flexible spending arrangements may be able to cover the drugs, they said.

And patients with medical conditions like diabetes and heart disease can still get coverage for weight-loss drugs through IBX.

"This change only applies to weight loss drugs (e.g., GLP-1 and non-GLP-1 drugs) when they are prescribed solely for weight loss and not for any other medical conditions that the FDA has approved them for," the company said in a statement.

The company also encouraged patients with IBX plans to use "nonprescription options" for weight loss like behavioral health, nutritional counseling, reimbursement for gym memberships, and bariatric surgery.

Staff writers Alison McCook and Harold Brubaker contributed to this article.

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