Medications have helped WV residents lose weight, but coverage can be a problem

Mike Plante struggled with his weight for years, but within six months of starting with the injection drug semaglutide, a medication for diabetes that's also being used for weight-loss, he's down 65 pounds.

"I still have an appetite; I just get full quicker," Plante, of South Charleston, said. "So, I'm eating less of things. But as I lost weight, I felt more like being active. So I've rejoined the gym, and I've been exercising regularly and getting about 12,000 steps a day ... . And so from my perspective, the medication has worked."

But had it been up to his insurance, Plante might not have gotten the drug or lost the weight. Although Plante was classified as morbidly obese, his insurance plan through the federal health insurance marketplace wouldn't cover the drug because he isn't diabetic. Instead, he pays nearly $500 a month for the drug through Reflex MD, a company that's "basically a compounding pharmacy," he said.

"The cost of these things is prohibitive for a lot of people to get on them if your insurance doesn't cover it," he said. "And, at my age, with the weight, it wasn't really a question of if I was going to have a stroke or get diabetes, it was a question of when.

"This has helped me reverse those trends," Plante said. "And, I think that's worthwhile. It should be something that insurance covers."

Some West Virginia residents say the drugs have helped them lose weight, but it's often difficult to get insurance plans to pay for the costly drugs.

A proposal by the Biden administration would expand access to the weight loss drugs to hundreds of thousands of West Virginia residents. The proposal would reinterpret federal law so that Medicare and Medicaid would be required to pay for the drugs to treat obesity. The medications can range from $936 to $1,349 for a month's supply.

The rule change is subject to approval by President-elect Donald Trump.

Medicaid covers 250,000 West Virginians, while more than 450,000 West Virginians are eligible for Medicare. Currently, Medicare part D, the program's outpatient drug benefit, pays for the drugs only when they're used for a medically accepted FDA-approved indication other than obesity, like diabetes or cardiovascular disease risk reduction, according to KFF.

State Medicaid programs are required to pay for the drugs when they're indicated for co-morbidities like diabetes or cardiovascular disease risk. Only 13 states — not including West Virginia — cover the drugs for obesity treatment.

Coverage 'a very big problem'

Dr. Bisher Mustafa, a Marshall Health physician and a professor in the Joan C. Edward School of Medicine, prescribes the weight loss drugs to his patients. He said people often have trouble getting their insurance companies to cover them.

"[Coverage] has been a very big problem, especially in West Virginia, because of the redundancy of the coverage, where insurance has covered it in the beginning, and then they backed off because of the cost," he said. "And of course, we had patients in Medicaid who have not been getting the coverage unless they are diabetic.

"So we feel a little bit bitter about waiting for my patient to become diabetic until we use it," he said. "The aim is to prevent that. [It] should maybe be used for pre-diabetes."

Mustafa said the medications are "very successful" at helping people lose weight. There's evidence that they help people's hearts and prevent strokes too, he said.

"The data has been astonishing, especially the success of this weight loss," Mustafa said. "There has been no other medication since the 50s that when we started using some medication that's been more successful in weight loss, and doing it in a sound, metabolic way. So we're very excited."

Mustafa said that data shows that these medications are safer than other weight loss medications.

"The history of obesity medication has been very — I'm not going to say tragic, but I will say very dim and disappointing," he said. "Because quite a few medications came and left where we discovered some side effects."

Mustafa said his patients are treated with a "multidisciplinary" and "holistic" approach because patients who stop using the medications run the risk of gaining the weight back.

"People have to take their medicine. But at the same time, change their lifestyle together," he said. "[T]hey have to talk to the dietician, they have to engage in physical activity. Also, they have to sometimes talk to psychologists about stress eating or emotional eating or boredom eating. So they come hand in hand.

An 'amazing tool' for weight loss

Since Morgantown resident Hilaria Swisher started taking Zepbound, she's lost a third of her body weight, dropping from 236 pounds to 157 pounds.

"I have so much more energy and a lot more confidence," Swisher said. "We like to go camping. We have a big camper, and I like to go hiking when we're camping, and I finally have the energy to do that. I can keep up with others. I'm not sore afterwards.

"I'm able to show those around me a confident me, and in turn, it helps them, especially my 12-year-old, be confident in her own skin as well," she said.

Swisher was always "the chubbier one" between her and her sister, but her weight struggles took off in 2010, when she stopped smoking.

"As soon as I quit smoking, even though really nothing changed (I wasn't eating anymore that I know of), the weight just came on, and I couldn't get rid of it," Swisher said. "But I told myself I'd rather be overweight, because it has to be healthier than smoking."

Because of polycystic ovary syndrome, a chronic hormonal condition, it was nearly impossible for Swisher to lose weight on her own, she said.

While taking the drug has been successful for Swisher, she'll soon run into a problem that many face when trying to get access to the drug. Her insurance plan — through the West Virginia Public Employees Insurance Agency — stopped covering it for weight loss. Citing the cost of the drugs, PEIA earlier this year paused a pilot program that paid for the drugs when used to treat weight loss. Officials have said the cost of GLP-1 drugs are one of the drivers of increased PEIA premiums. She's been rationing the drugs — taking them every two weeks instead of once per week — but worries over the day she'll finally run out.

"[I'm] extremely nervous," Swisher said. "I notice as I get closer to that two-week mark, that my weight starts to creep back up, and it's not because I'm eating more. It's not because I'm eating bad. It's not because I'm not moving as much. It's that those hormones start to kick back in, that the GLP-1 drugs are putting at bay, or however they work."

As a PEIA member, Swisher wouldn't benefit from the Biden administration's proposal, but she said she supports expanding access to the drug.

"I think that it is an amazing tool that we have at our fingertips that helps push back other health issues, and so I think it would be an amazing opportunity for so many Americans, especially so many West Virginians who don't have access to healthy foods that, thankfully I do," Swisher said.

Sarah Sigmond, of Sissonville, has been using the drug Wegovy since July, and has already lost 17 pounds.

Sigmond said she's struggled with weight for 20 years and tried everything to lose it.

"I'm somebody that has done everything that they were supposed to do, that can tell you exactly how many calories I'm taking, how many calories I'm supposedly burning," Sigmond said. "And, it's all I can do to keep from gaining and I can't lose without help. And even if I don't lose any more than what I already have, I feel better. So [weight loss drugs are] not going to solve every problem, but it definitely is helpful."

Last year, when her doctor first prescribed her the drug, it would have cost Sigmond more than her monthly mortgage payments, she said, despite having insurance coverage, something she couldn't afford.

But after exhausting other weight loss plans, she was able to get the drugs reasonably covered and start taking them this summer. Now, she's hearing that requirements for covering the drugs may change and the plan may only cover it for people with diabetes. Sigmond wouldn't be covered even though she is prediabetic.

"When this was the cost of my mortgage payment to get a dose, I couldn't do that," she said. "And if it goes back there again, I still won't be able to do it. But as long as I can get it and my insurance is covering it reasonably, it is something that I think should be available, because there's so many other health problems that the weight causes."

Costs to West Virginia are 'uncertain'

West Virginia has one of the highest obesity rates in the country. According to the Centers for Disease Control and Prevention, it was one of three states where more than 40% of residents were obese in 2023.

According to the Department of Human Services, Medicaid, a joint state and federally funded program, covers an estimated 250,000 adults in West Virginia. As of November, more than 450,000 West Virginians were eligible for Medicare, a federal health insurance program for people ages 65 and older, according to the Centers for Medicaid and Medicare Services.

The proposed change is expected to cost the federal government $25 billion for Medicare and $11 billion for Medicaid over the next decade. States would pay $3.8 billion for Medicaid coverage throughout the same time period.

It's unclear how much it would cost West Virginia if Medicaid were to cover the weight loss drugs.

Whitney Wetzel, a spokeswoman for the West Virginia Department of Human Services, pointed West Virginia Watch to a fiscal note for legislation that would have created a supervised weight loss program for the state's Medicaid recipients. Senate Bill 743 would have covered the drugs for Medicaid recipients. The bill did not get traction after it was introduced during the regular 2024 legislative session.

According to the Department of Human Services, the program would have cost $75.6 million for a year — $55.8 million from the federal government and $19.7 million from the state. The estimate is based on 2024 drug costs.

But the qualifications for SB 743 would have been different from that of the Biden administration's proposal.

Under Biden's proposal, Medicaid would cover the cost of the drugs to treat obesity, regardless of whether the patient has a co-morbidity like type two diabetes or hypertension.

West Virginia's proposed program would have been open to Medicaid recipients with a body mass index of at least 35 and at least one of the following comorbidities — hypertension, metabolic-associated fatty liver disease, obstructive sleep apnea, coronary heart disease or type 2 diabetes. The department estimated that 30% of the 250,000 adults in the Medicaid program would qualify for the program and assumed that 30% would pursue the option.

"The proposed rule is currently just that — a proposal," Wetzel wrote. "Its potential implications for West Virginia remain uncertain at this stage and are subject to further evaluation and development."

Justice supports Biden, says he takes Ozempic

Gov. Jim Justice, who was recently elected to the U.S. Senate, told reporters recently that he has been taking the drug Ozempic— a GLP-1 used to treat diabetes and weight loss — and that he's lost "30, 40 pounds, maybe even 50 pounds."

Justice said he doesn't know how to expand access to the drugs "from the standpoint of the cost" and said sustainability must be part of the puzzle.

"For all I know about these drugs, they are beneficial in many different ways," Justice said. "And the net net of the whole thing at the end of the rainbow — it'll save us money. It'll save us money. But we've got so much that we've got to do to overhaul this colossal mess in D.C. It's unbelievable. That's just all there is to it.

"I would be a proponent of trying to do everything we can to be able to expand these drugs that you're talking about to everybody," Justice said. "Because at the end of the day it will save us tremendous amounts of money."

A representative for West Virginia Gov.-elect Patrick Morrisey did not respond to an email asking if Morrisey supported President Joe Biden's proposal.

Mustafa agreed with Justice's assessment that covering the drugs would save government money in the long run.

"I feel that losing weight, we're going to provide cutting costs for hospitalization, like for heart disease, for strokes, for many other obesity related diseases," he said. "Also it's going to cut costs on the various costs, maybe amputations, renal failure, dialysis. Also it's going to cut costs on sleep apnea and using devices.

"So, I feel there's definitely a saving cost down the road by decreasing incidence of obesity or reducing the BMI," he said.