Spotty insurance coverage for GLP-1 drugs gets worse

MARY LOUISE KELLY, HOST:

Obesity medicines Wegovy and Zepbound have gone mainstream. They work well for people looking to lose weight. Doctors are comfortable prescribing them. But NPR pharmaceuticals correspondent Sydney Lupkin reports insurance coverage has not kept pace.

SYDNEY LUPKIN, BYLINE: For Megan Lena (ph), a special ed teacher in Massachusetts, the letter she got last spring from the company that manages her drug benefits really hurt. CVS Caremark said it was dropping Eli Lilly's blockbuster obesity drug Zepbound from its coverage in July.

MEGAN LENA: I was devastated.

LUPKIN: She'd been able to afford the $30 copay for Zepbound and lost 50 pounds in a year. Lena wound up switching to Wegovy , CVS Caremark's new preferred drug at the same copay, and was relieved that it worked for her. But just a few months later, in October, her employer's health plan dropped Wegovy, too.

LENA: It felt like a double punch. And that's kind of the point where I was like, I guess I can't make it work.

LUPKIN: She felt defeated. Making matters worse, her monthly health insurance premium went up 20%. The school district's insurer sent a letter saying it was because of expensive GLP-1s, the same ones that were no longer covered.

LENA: That was the first moment that I was like, holy cow, these insurance companies - they're now making medical decisions for me. And that really, really made me mad.

LUPKIN: Lena is one of the many people who lost coverage for these medicines. That's according to research by GoodRx, a website that helps patients find discounts on prescription drugs. It found that over the last year, 12 million people lost coverage for Zepbound, and 12 million lost it for Wegovy. Amanda Nguyen, the senior health economist at GoodRx, says without adequate coverage, the drugs cost people hundreds of dollars a month.

AMANDA NGUYEN: For many Americans, they can't afford that. So that's the difference between - for many people - taking the medication that their doctor wants them to take and having to forego it.

LUPKIN: With coverage, the common restrictions include a prior authorization or, something I've heard from a lot of patients, that the insurance plan requires a body mass index, or BMI, of 40. That's well above the obesity threshold of 30. Sometimes even people who do have coverage still have to pay hundreds of dollars a month because their plans only pay for a small percentage of the drug's price.

TRACY ZVENYACH: There are, like, the lucky ones that have some form of coverage that is also affordable. But they are few and far between.

LUPKIN: That was Tracy Zvenyach, the vice president of advocacy and research at the nonprofit Obesity Action Coalition, which receives financial support from drugmakers, including Eli Lilly and Novo Nordisk.

ZVENYACH: Essentially, every insurance carrier is just making it up - making up the policy, the limitation, the restriction on eligibility in the way that they want to, in a way that will, you know, kind of reduce the eligible population.

LUPKIN: In Virginia, Dr. Catherine Varney is the obesity medicine director for UVA Health. She has about a thousand patients on obesity drugs, and she says 60% of them are paying out of pocket, and insurance coverage barriers are growing.

CATHERINE VARNEY: I feel like more of a financial planner these days than a physician because we're crunching the numbers.

LUPKIN: The Pharmaceutical Care Management Association says employers and their pharmaceutical benefit managers are working to expand coverage for GLP-1s and have made huge progress despite significant cost challenges. Asked about dropping Zepbound in favor of Wegovy, CVS Caremark says its formulary strategy uses competition to drive down costs. It says the drug company's high prices for Zepbound and Wegovy are the biggest barrier to patient access.

As for Megan Lena in Massachusetts, her doctor works with a compounding pharmacy he trusts and helped her switch to a medication she can afford. Compounded drugs aren't generics. They're made with the same active ingredient as the brand-name versions but by a specialized pharmacy, not a drug company.

LENA: There's so much uncertainty around these medications. Am I going to be able to get it? Can I afford it? Is it going to change? Is it ever going to be affordable?

LUPKIN: Lena now pays about $300 a month for compounded medicine, compared to Eli Lilly's 450 cash price for her dose of name-brand Zepbound. It's expensive, but she says it's her best option for now. Sydney Lupkin, NPR News. Transcript provided by NPR, Copyright NPR.

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