June 19, 2024

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Doctors’ Tips for Accessing Costly GLP-1 Therapies

5 min read

“Does your insurance cover anti-obesity drugs?” Laura Davisson, MD, once again asked the patient before her. She said these cost-of-care conversations are now a daily occurrence.

While glucagon-like peptide 1 (GLP-1) agonist drugs like Ozempic hold tremendous promise in tackling diabetes, obesity, and other disorders, costs remain a significant concern and, for some patients, a roadblock. Physicians must have nuanced discussions with patients about how to afford the high-cost treatments as they increase in popularity, Davisson said.

“We don’t get trained in how the healthcare system works in medical school or residency,” said the internist and director of medical weight management at West Virginia University in Morgantown, West Virginia. “All of a sudden, we’re faced with questions about how patients can pay for these medications.”

It’s not uncommon for out-of-pocket GLP-1 costs to reach hundreds of dollars per month — even up to $1000 or more, said Davisson. That expense isn’t sustainable for most, but there are strategies physicians can use to improve affordability for their patients.

Wading Through the Maze of Insurance Benefits

According to a recent KFF survey, about one in eight US adults has tried injectable drugs. However, half of those respondents no longer take the medication, and about the same number indicated the costs were prohibitive even with insurance.

Like most other treatments, coverage for GLP-1 drugs varies widely based on payer and diagnosis. Davisson said physicians should consider patients’ insurance benefits when advising them on the medication’s high costs.

The expense can make it a “nonstarter” for many patients without coverage.

Confusingly, insurance companies will typically cover GLP-1s, like Ozempic and Mounjaro, with a diabetes diagnosis but exclude the US Food and Drug Administration–approved versions for weight loss, such as Wegovy or Zepbound. This generally holds for most insurances, whether Medicare, Medicaid, or commercial, unless an employer-sponsored health plan opts into coverage for GLP-1 weight loss drugs. In Davisson’s experience, about one third of them do.

If the patient has not had a recent A1c blood test or a 2-hour glucose tolerance test, she recommends ordering those first to see if they meet the criteria for diabetes. “You don’t really want to root for someone to have diabetes, but it certainly opens up more [medication] options,” said Davisson.

Medicare may provide broader coverage for weight loss injectables if Congress eventually passes the Treat and Reduce Obesity Act, first introduced in 2013. Until then, there is some “wiggle room” for doctors to get the medications covered for nondiabetic Medicare patients.

“Recent data showed a 20% reduction in cardiovascular events in people with a known history of coronary disease, so you can now access GLP-1s through that coronary disease indication,” Davisson explained.

Explore Patient Assistance Programs

Some GLP-1 manufacturers offer patient assistance programs that can offset the cost if patients qualify and meet income limitations, said Sarah Kokosa, PharmD, CPP, a clinical pharmacist at Duke Health’s Endocrinology Clinic in Durham, North Carolina. She said these programs are a good option for uninsured or Medicare patients who cannot afford the out-of-pocket expenses.

Another option for Medicare patients is the Low Income Subsidy, or “Extra Help” program. She said providers can direct patients to this online resource or an organization with Medicare counselors, such as the State Health Insurance Assistance Program, to assist with the application process.

For patients with commercial insurance but a high deductible or copay, Kokosa suggested using manufacturers’ savings cards. Depending on their insurance coverage, these coupons can reduce patients’ monthly costs to $25 or less.

Davisson follows the recommendations of several obesity industry groups, which advise patients to stick with traditional pharmacies instead of pursuing compounded alternatives. Although compounded GLP-1 drug pricing may initially appear enticing, she said the advertised cost is often for the lowest dose. Some patients do well at this dose, but others don’t.

The cost rises quickly. “We’ve had patients on the highest dose at a compounding pharmacy paying $600. If they use the coupon card with their commercial insurance, they can get it for less, about $550 a month, from an actual legitimate pharmacy,” said Davisson.

Call in Reinforcements

Unfortunately, assistance programs are often temporary, lasting as little as 6 months, said David D’Alessio, MD, chief of the Endocrinology and Metabolism Division at Duke University School of Medicine in Durham, North Carolina. The assistance tends to skew toward “younger, richer, more tech-savvy patients,” raising concerns about health equity, he said.

Research showed that some racial and ethnic groups, like Black adults and Hispanic youth, have higher rates of diabetes. Obesity is also more prevalent among minority populations. Physicians may need to be more proactive in ensuring these groups receive information about available assistance programs and resources.

Electronic medical record systems may provide cost estimates at the point of care. Kokosa said these are not always accurate, so the patient or physician’s office must perform additional legwork. Practices can run the prescription to obtain truer pricing.

However, the paperwork can be cumbersome for less-resourced offices, so Davisson counsels patients on GLP-1 medication names and how to contact the insurer to verify coverage and prior authorization requirements.

The lack of pricing transparency means patient education for high-cost drugs is critical.

“I spend a lot of time educating patients on how to obtain medication coupons for themselves, encouraging them to become familiar with their insurance’s deductibles, preferred pharmacies, and formularies, or helping them understand how out-of-pocket medication costs may change during the various coverage phases of Medicare Part D,” said Kokosa.

She also coordinates with the health system’s pharmacy technicians to assist patients in exploring insurance benefits and discount programs, plus social workers to identify other community resources, like transportation and food access, that can ease patients’ socioeconomic hardships.

Barring significant changes in insurance coverage for anti-obesity drugs, cost-conscious patients and their doctors may have to wait for generic versions of GLP-1s to hit the market.

“Liraglutide is supposed to go generic in the next year or 2, but probably at the diabetes dosing,” said Davisson, adding that it’s unclear if clinicians will be able to prescribe it off-label and at a higher dosage for obesity treatment.

Generics of semaglutide, one of the most promising anti-obesity drugs to date, are several years away. For now, experts say physicians will need to broach the topic of medication cost early on and formulate a backup treatment plan, such as prescribing lower-cost oral medications like phentermine and topiramate, should the new GLP-1s remain financially out of patients’ reach.

Steph Weber is a Midwest-based freelance journalist specializing in healthcare and law.

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