For Debbie Halstead, Wegovy has proven to be a transformative weight loss treatment.

This resident of Cool Ridge, West Virginia, has lost 60 pounds and significantly reduced her blood pressure. Furthermore, Novo Nordisk’s popular weight loss drug has alleviated her severe knee arthritis, making her feel “much, much better,” she shared.

Starting January 1, her federal Blue Cross Blue Shield health insurance plan will modify how it covers glucagon-like peptide 1 (GLP-1) drugs like Wegovy and Ozempic. These medications will be moved to a higher cost tier on her plan.

The medication she currently pays $25 monthly for will jump to a staggering $713 monthly.

“Even if I don’t lose another pound, I want to keep taking this medication,” Halstead remarked. “But at $700 a month, that’s just not feasible.”

Despite the increasing popularity of weight loss drugs such as Wegovy and Zepbound, many working adults find it challenging to afford these treatments. Some are facing rising out-of-pocket expenses due to higher co-pays or other shifts in insurance costs.

Others are completely denied coverage, forcing them to pay for the medications themselves, search for discount coupons, or obtain off-brand and potentially unsafe versions from compounding pharmacies.

Data shows that only around one-third of individuals prescribed these medications stay on them for a year or more, even though these drugs are meant for lifelong use, similar to blood pressure medications, and discontinuing them typically leads to regaining lost weight.

In a country where 42% of adults are obese, many feel frustrated that high prices and inconsistent insurance coverage for GLP-1s have severely restricted access.

Some Blue Cross Blue Shield plans have declared they won’t cover weight loss drugs at all. In states like North Carolina, those on state health insurance plans can no longer access coverage for weight loss medications due to exorbitant costs.

Individuals who purchase their insurance privately are also unlikely to see coverage for anti-obesity drugs like Wegovy and Saxenda. Just 1% of Affordable Care Act marketplace plans included them in their benefits this year, according to a June analysis by KFF, a nonprofit health policy think tank.

For Medicare, the federal health program serving adults aged 65 and older, coverage is restricted to those with diabetes or heart conditions.

This past Tuesday, the outgoing Biden administration revealed a proposal to extend coverage for obesity medications to over 7 million Medicare and Medicaid recipients starting in 2026. However, this rule needs to be finalized after President-elect Donald Trump assumes office in January, and it’s uncertain if his administration will be willing to absorb the estimated $40 billion cost.

Insurance Coverage for Weight Loss is the ‘Biggest Barrier We Have’

Many people struggle to pay for these promising weight loss medications due to insurance limitations, according to Dr. Angela Fitch, former president of the Obesity Medicine Association.

“Insurance coverage for weight loss is the largest obstacle we face in the United States, as it is not considered a standard benefit,” said Fitch, who is also co-founder and Chief Medical Officer of knownwell, a provider of obesity and primary care services in Boston and Dallas. She believes denying coverage for weight loss should be deemed unacceptable, immoral, and potentially negligent given the current evidence.

The high prices and limited insurance access have left consumers feeling dissatisfied.

Halstead, who works for the Veterans Health Administration, recently received a letter from Blue Cross Blue Shield informing her of the upcoming price hike for her anti-obesity medications effective January 1.

In response to the financial burden she’ll face in January, she has been searching for manufacturer coupons. Novo Nordisk provides a $225 coupon that would reduce her monthly cost to under $500, but that amount will still be hard to manage.

Halstead has previously tried dieting and underwent weight-loss surgery, but none have been as effective as GLP-1 medications, according to her. Since shedding weight, she has discontinued her cholesterol medication and hopes to stop taking blood pressure medication soon.

She raises a critical point about whether insurance companies are overlooking the long-term benefits of covering weight loss drugs that could improve countless lives and reduce the need for other ongoing medications.

“Is it less expensive to be overweight and continuously visit doctors for all the related health issues?” Halstead posed. “It is disheartening and unjust that Americans are stuck in this cycle of corporate greed.”

The Blue Cross Blue Shield Association stated that the federal employee insurance program “consistently reviews the use and costs of prescription medications and updates the covered drug lists each year. As we have previously done, we continue to provide access to various covered weight loss prescription medications.”

Anti-Obesity Medications Are Expensive for Employers

While many consumers face significant out-of-pocket expenses, employers are working to manage the rising costs of these medications.

A recent Mercer survey highlights that the rising use of GLP-1 medications contributes to prescription drug expenses being the fastest growing element of employer health costs. In 2024, these costs rose by 7.7%, which is a slight decrease from the 8.4% increase seen in 2023.

Most health plans include coverage for GLP-1 medications used to treat diabetes, and an increasing number are also covering these drugs for weight management. According to Mercer, in 2024, 44% of large employers provided coverage for GLP-1 medications aimed at obesity, an increase from 41% the previous year.

However, only 5% of companies permitted their employees to access GLP-1 weight loss drugs without any restrictions. As mentioned by Mercer, most employers set conditions that must be met before their employees can receive these drugs, like having to meet certain BMI criteria or getting prior authorization for prescriptions, and sometimes even requiring consultations with dietitians.

Businesses aim to reduce the number of individuals seeking weight loss medications for non-essential or cosmetic reasons.

“Employers have been more proactive this year by imposing certain limitations,” noted Beth Umland, Mercer’s director of health and benefits research.

The steep list prices of these new weight-loss medications are straining taxpayer-funded healthcare programs. The Biden administration projects that expanding coverage for anti-obesity drugs for Medicare and Medicaid recipients in 2026 could cost around $40 billion over ten years. This hefty expense has led some lawmakers to advocate for more actions to control drug prices set by manufacturers.

U.S. Representative Lloyd Doggett, a Democrat from Texas, has called on the Biden administration to tackle “price gouging” associated with branded GLP-1 drugs by permitting generic competition. These drugs are protected by patents, with Wegovy’s patent not ending until 2032 and Zepbound’s until 2039.

Despite this patent protection, Doggett and other Congressional members argue that the federal government has the power to allow generic manufacturers to enter the market in return for “reasonable compensation” to the brand-name drug creators.

“Forcing Medicare and Medicaid to cover medications, for which they currently lack negotiation power over prices, will invariably inflate expenses – costing taxpayers billions, driving up premiums, and jeopardizing the stability and promise of Medicare,” Doggett stated.

High costs drive consumers to find alternatives

35-year-old Amanda Bonello recognized she needed to take action when her recent blood test indicated that her elevated blood sugar levels put her at risk for diabetes. Residing in Marion, Iowa, the mother of three was concerned about her family’s medical history, as her mother has diabetes and her father has pre-diabetes.

Her doctor informed Bonello that if her blood sugar was not managed, she would prescribe metformin, a common diabetes medication.

“I wanted to find a better alternative,” Bonello said.

She then consulted her doctor about tirzepatide, a diabetes treatment marketed as Mounjaro and for weight loss under the name Zepbound.

Unfortunately, Bonello’s workplace insurance would not cover Mounjaro because she had pre-diabetes instead of diagnosed diabetes. The weight-loss drug Zepbound was also not covered, with a retail price exceeding $1,000 for a month’s supply. Consequently, she located a telehealth provider who could prescribe a more affordable version procured from a compounding pharmacy.

For $211 out of pocket, she secured a month’s supply of the weekly injections. Without health insurance, she stated that she could not afford the brand-name version. As claimed by Eli Lilly, patients lacking coverage for Zepbound can purchase it for $650 per month.

Bonello has been using the compounded version for a month, resulting in a weight loss of 18 pounds. She estimates she needs to lose about 50 more pounds to reach her desired weight.

“I feel absolutely amazing,” Bonello exclaimed, sharing that she has more energy, frequently walks, and can keep up with her three sons, including a teenager and two 12-year-olds.

Yet, she remains concerned about her ongoing access to the affordable, compounded version of tirzepatide.

The FDA permits compounding pharmacies to distribute copies of medications when shortages occur. Zepbound and Mounjaro had been in short supply since 2022, but on October 2, the FDA announced these products were no longer considered in shortage. Once this status change occurs, compounding pharmacies face stricter regulations. Additionally, the FDA has warned against the use of these compounded medications.

A trade group for compounding pharmacies has filed a lawsuit against the FDA, and the agency has agreed to revisit its recent decision to declare the shortages resolved. In a letter dated October 17, the FDA informed the Alliance for Pharmacy Compounding that No immediate enforcement action will be taken.

However, this uncertainty has raised concerns among consumers like Bonello, who depend on these compounded medications. A Change.org petition has garnered over 7,000 signatures, urging the FDA to maintain access to compounded versions.

“If only brand-name options are available, many people won’t be able to afford them, which would strip hope and health from countless individuals,” Bonello expressed.