Many insurance companies refuse to cover new weight loss drugs that their doctors deem medically necessary.
By Gina Kolata
- May 31, 2022
Maya Cohen’s entree into the world of obesity medicine came as a shock.
In despair over her weight, she saw Dr. Caroline Apovian, an obesity specialist at Brigham and Women’s Hospital, who prescribed Saxenda, a recently approved weight-loss drug. Ms. Cohen, who is 55 and lives in Cape Elizabeth, Maine, hastened to get it filled.
Then she saw the price her pharmacy was charging: $1,500 a month. Her insurer classified it as a “vanity drug” and would not cover it.
“I’m being treated for obesity,” she complained to her insurer, but to no avail.
While Ms. Cohen was stunned by her insurer’s denial, Dr. Apovian was not. She says it is an all too common response from insurers when she prescribes weight-loss drugs and the universal response from Medicare drug plans.
Obesity specialists despair but hope that with the advent of highly effective drugs, the situation will change.
Novo-Nordisk, the maker of the medicine Dr. Apovian prescribed, and patient advocacy groups have been aggressively lobbying insurers to pay for weight-loss drugs. They also have been lobbying Congress to pass a bill that has languished through three administrations that would require Medicare to pay for the drugs.
But for now, the status quo has not budged.
No one disputes the problem — more than 40 percent of Americans have obesity, and most have tried repeatedly to lose weight and keep it off, only to fail. Many suffer from medical conditions that are linked to obesity, including diabetes, joint and back pain and heart disease, and those conditions often improve with weight loss.
“The evidence is now overwhelming that there are physical changes in weight regulating pathways that make it difficult for people to lose weight and maintain their weight loss,” said Dr. Louis Aronne, an obesity medicine specialist who directs the comprehensive weight control center at Weill Cornell Medicine. “It’s not that they don’t have willpower. Something physical is holding them back.”
Dr. Aronne and other obesity medicine specialists emphasize that obesity is a chronic disease that should be treated as intensively as heart disease, diabetes, high blood pressure or any other chronic illness are. But, they say, that rarely happens.
“Access to medicines for the treatment of obesity is dismal in this country,” said Dr. Fatima Cody Stanford, an obesity medicine specialist at Massachusetts General Hospital and Harvard Medical School.
But even if a patient’s insurer will cover weight loss drugs, most doctors do not suggest the drugs and most patients do not ask for them, as they fail to realize there are good treatment options, said Dr. Scott Kahan, an obesity medicine specialist in Washington, D.C. And, he added, even if doctors and patients know there are F.D.A. approved drugs, many think they are “unsafe or not well studied and that everyone regains their weight.”
The medical system bears much of the blame, Dr. Stanford said. Just 1 percent of doctors in the United States are trained in obesity medicine. “It’s the biggest chronic disease of our time, and no one is learning anything about it,” she said.
Data on medication use by patients predate the newer, more effective and safe drugs made by Novo Nordisk and Eli Lilly. Still, obesity medicine doctors say, they doubt that the number has changed much from the earlier studies that found that less than 1 percent who are eligible obtained one of these drugs. That is about the same percentage as those who get bariatric surgery, which most insurers, including Medicare, pay for.
“The perception is, ‘If you are heavy, pull yourself up from your bootstraps and try harder,’” Dr. Kahan said.
And that, he adds, is a perception many patients, as well as doctors, share, making them reluctant to seek medical help or prescription medications.
Then there is the problem Ms. Cohen ran into: Insurers that do not cover weight-loss drugs.
But some obesity specialists have found a strange workaround to get an effective but expensive Novo Nordisk drug for patients with obesity whose insurers will not pay.
The workaround exploits quirks in the way Novo Nordisk markets its drugs. The company sells a drug, semaglutide, for both diabetes and for obesity. As a diabetes drug, it is called Ozempic and has a list price of $892 for four weeks. It is easily available at pharmacies, and insurance companies cover it for people with diabetes.
Novo Nordisk sells two weight loss drugs that are of the same class in two doses — liraglutide as Saxenda, and semaglutide at a higher and more effective dose as Wegovy. The list price — the suggested retail price — for both is about $1,350 a month. That means the same drug costs 51 percent more if it is used to treat obesity than if it is used for diabetes.
But as an obesity drug, it is hard to get.
Not only do most U.S. insurers decline to pay for Saxenda or Wegovy because they are weight-loss drugs, but Wegovy supplies are so limited that the company has asked doctors not to start new patients on it.
Eli Lilly has a similar and seemingly more powerful weight-loss drug, tirzepatide, which it hopes to get approved for people with obesity. It was recently approved to treat diabetes under the name Mounjaro. As a diabetes drug, its retail price is $974 a month.
Douglas Langa, an executive vice president at Novo Nordisk, said the Wegovy supply problem was caused by a manufacturing issue that should be resolved later this year.
He also said that diabetes and obesity were “separate categories, separate marketplaces” to explain the difference in price between the companies’ two drugs that were based on the same medicine, semaglutide. He said Wegovy’s price “reflects efficacy and clinical value in this area of unmet need.”
Dr. Stanford was appalled.
“It’s unbelievable,” she said, adding that it was a gross inequity to charge people more for the same drug because of their obesity. She finds herself in an untenable situation: getting excited when her patients with obesity also have diabetes because their insurers pay for the drug.
Dr. Apovian says she too finds herself rejoicing when patients have high blood sugar levels — and that was what ultimately resolved Ms. Cohen’s problem.
Her insurance company would cover Ozempic, but it would not cover Saxenda. So she started taking Ozempic, with a $70 a month copay.
Ms. Cohen — who measured at five feet tall and weighed 192 pounds when she saw Dr. Apovian — had a dramatic response to Ozempic. She has lost 54 pounds and now weighs 138 pounds. Her waist size, which was 46 inches, is now 33 inches. She has more energy and her joints do not hurt.
“It has absolutely changed my life,” Ms. Cohen said.
Gina Kolata writes about science and medicine. She has twice been a Pulitzer Prize finalist and is the author of six books, including “Mercies in Disguise: A Story of Hope, a Family’s Genetic Destiny, and The Science That Saved Them.” @ginakolata • Facebook
A version of this article appears in print on June 1, 2022, Section A, Page 17 of the New York edition with the headline: Many Insurers Won’t Cover New Weight Loss Drugs. Order Reprints | Today’s Paper | Subscribe
According to the Canadian Mental Health Association (CMHA) mental health is not only the avoidance of serious mental illness. Your mental health is affected by numerous factors from your daily life, including the stress of balancing work with your health and relationships. In this section you will find resources to help you stay mentally fit and healthy.
It’s easy to book an appointment with one of our Mental Health counsellors by discussing your concern during an appointment with a Nurse Practitioner or a Family Physician. They will take it from there and make the connection for you. You’ll receive a call from our clinic letting you know when you’re appointment is.
Knowing you need help and asking for it is important – and understandable. There is no stigma to asking for help with mental health concerns. Our two Mental Health Counsellors, Kelly and Susanna are here to help. We know you will feel welcome, supported and understood under their care.
As part of Mental Health Week 2022 we’d like to introduce you to our Mental Health team and find out a little about the best part of their day at Winterberry and also why they choose to become mental health care providers.
Kelly Nancekivell, Mental Health Counsellor
The best part of my day is being able to connect with patients of the clinic and provide a safe space for them to talk about their concerns. I love seeing their progress over time and their ability to use their own strengths to identify solutions to some of their problems. I appreciate the relationships I get to make with the people I serve at Winterberry, and I truly value the opportunity to provide easier access to mental health help and resources.
I chose to be a Mental Health Counsellor at Winterberry because I love the collaborative components and the ability to work within a multidisciplinary team. I love that there is wrap-around support for patients concerns because they have access to so many different professionals who can help them navigate their path to mental and physical wellness. Since mental and physical health are very much interconnected, I feel this approach is very beneficial and meets the needs of the people we work with. I am grateful to be a part of the compassionate, caring team at WFM, and am proud to empower the patients at the clinic to reach their mental health goals.
Susana Cadavid, Mental Health Counsellor
The best part of my day is being able to call each patient and spend the session supporting them. Meeting them wherever they may be on that day, supporting their needs that day, and hearing the sense of relief as the call comes to an end. Being able to make a difference in someone’s life makes every day a dream come true. Knowing that I am helping people is my favourite part of my day.
Becoming a Mental Health Counsellor was an easy choice for me. Having experienced struggles with mental health myself, I can appreciate how crucial it is to have someone who will listen non judgmentally, support objectively, and provide resources. Being a Mental Health Counsellor allows me to do this and more for the patients we see at Winterberry. Patient centred and multidisciplinary care are two things I am very proud to be part of here.
To book an appointment with one of our mental health care providers, talked to a Nurse Practitioner or Family Physician and share your concerns. They will work with our administrators to book you an appointment as soon as possible.
Benefits of large weight loss were observed in patients with various overweight- or obesity-related complications, including improvements in comorbidities such as type 2 diabetes and hypertension.
Improvements in glucose metabolism and cardiovascular risk factors were observed in patients who achieved large weight loss through lifestyle interventions or pharmacotherapy (phentermine/topiramate 15/92 mg once daily or subcutaneous semaglutide 2.4 mg once weekly).
Other benefits associated with large weight loss included reduced cancer risk and improvements in knee osteoarthritis, sleep apnea, fertility-related end points, and health-related quality of life.
While costly, bariatric surgery is currently the most cost-effective intervention, although most weight-management programs are deemed cost-effective.
Conclusions: Overall, large weight loss has a major beneficial impact on overweight- and obesity-related complications. Large weight loss should be the main treatment target when modest weight loss has had insufficient effects on obesity-related complications and for patients with severe obesity.
Citation: Tahrani AA, Morton J. Benefits of weight loss of 10% or more in patients with overweight or obesity: A review. Obesity (Silver Spring). 2022 Apr;30(4):802-840. doi: 10.1002/oby.23371. PMID: 35333446.
TORONTO — The Ontario government, in consultation with the Chief Medical Officer of Health, is expanding eligibility for fourth doses of the COVID-19 vaccine to individuals aged 60 and over as well as First Nation, Inuit and Métis individuals and their non-Indigenous household members aged 18 and over starting on April 7, 2022. Expanding booster eligibility will provide an extra layer of protection against the Omicron and BA.2 variants and, in addition to antivirals, are another tool the province is using to live with and manage COVID-19.
“As we continue to live with COVID-19, we are using every tool available to manage this virus and reduce its impact on our hospitals and health system, including by expanding the use of booster doses,” said Christine Elliott, Deputy Premier and Minister of Health. “Vaccines are our best defence against COVID-19 and its variants. Because of our exceptionally high vaccination rates and Ontario’s cautious approach, we currently have one of the lowest hospitalization rates in the country and have performed well throughout this pandemic when compared to other similar sized provinces and states. I encourage everyone who’s eligible to get boosted as soon as you’re able.”
For more information read the full news release from the Ontario Ministry of Health at https://news.ontario.ca/en/release/1001961/ontario-expanding-fourth-dose-eligibility.
We welcome everyone in the community for COVID-19 vaccinations at Winterberry so please share the news with your family, friends and coworkers.
At Winterberry we’re honoured and proud to be nominated for three Reader’s Choice awards. We’re dedicating each of these nominations to our hardworking and skilled team as a way to thank them for helping our patient’s live their best life all year long.
Our clinic is nominated as best in these categories:
- Medical Health Services
- Medical Clinic
- Overall Service: Health/Wellness/Fitness/Beauty
We would love your support and vote:
It takes less than 10 seconds to vote in all three categories!
Two large scale studies provide evidence that higher-intensity (i.e., 12 or more sessions per year) interventions delivered by trained interventionists result in greater weight loss (13). These 2-year pragmatic cluster-randomized weight-loss trials conducted in underserved primary care settings were funded by the Patient-Centered Outcomes Research Institute (PCORI) in 2015 and were recently completed. The cluster design was used to minimize contamination between groups. To read the full study, click here.
At Winterberry we are proud to be part of our community’s COVID-19 vaccine efforts.
We are happy to announce that we will be offering COVID-19 vaccinations to children 5+. Appointments are available on our easy to use, instant booking page.
For full details see the COVID-19 information published by Ontario.ca.
TORONTO — Following Health Canada’s approval of the paediatric Pfizer COVID-19 vaccine, children aged five to 11 will be eligible to book their appointment to receive the vaccine beginning Tuesday, November 23, 2021. Approximately one million children aged five to 11 are eligible to receive the vaccine which will help protect Ontario’s progress in the fight against COVID-19 and keep the province’s schools safer and open for in-person learning as more people move indoors and attend family gatherings during the colder months this winter.
“The approval of the Pfizer vaccine for children aged five to 11 is exciting news for families and represents a bright light at the end of the tunnel,” said Christine Elliott, Deputy Premier and Minister of Health. “Offering the protection of the vaccine to children aged five to 11 is a significant milestone in Ontario’s fight against COVID-19 in advance of the holiday season. We continue to encourage all Ontarians to roll up their sleeves and get vaccinated to protect themselves, their families and their communities.”
As of 8:00 a.m. on Tuesday, November 23, 2021, children aged five to 11 across Ontario will be eligible to schedule a COVID-19 vaccine appointment through a variety of channels including the COVID-19 vaccination portal and contact centre, directly through public health units using their own booking system, participating pharmacies which individuals can find on Ontario’s website using the pharmacy locator, and select primary care providers.
To book an appointment online, children must be turning five years old by the end of 2021 (born in 2016).
Ontario is expected to receive 1,076,000 doses of the paediatric Pfizer COVID-19 vaccine from the federal government, which will then be immediately distributed to public health units, pharmacies, and primary care settings across the province. Appointments across the province are expected to begin as early as November 25 when the federal supply arrives at vaccine clinics across the province.
“Receiving vaccine approval for children aged five to 11 is another critical milestone in our vaccination efforts,” said Solicitor General Sylvia Jones. “Across the province, Ontarians have rolled up their sleeves to get vaccinated to stop the spread of COVID-19 and now parents can take comfort in knowing their children will also have the opportunity to be protected.”
“Increasing vaccine rates will help to further minimize disruption and keep students learning in a more normal in-class experience,” said Stephen Lecce, Minister of Education. “As a result of widespread ventilation improvements, increasing investments, and comprehensive testing options, Ontario has one of the lowest case rates for youth under 20 in Canada.”
In addition, the province, in conjunction with Health Canada’s First Nations and Inuit Health Branch, has launched Operation Remote Immunity 3.0 (ORI 3.0) to support the administration of COVID-19 vaccines for children aged five to 11 in Northern and Remote First Nation communities, as well as booster doses to eligible populations. ORI 3.0 will run until March 2022.
“Keeping a low rate of infection in our communities is vital to keeping our schools, our businesses and our social settings as safe as possible while minimizing disruption,” said Dr. Kieran Moore, Chief Medical Officer of Health. “The paediatric Pfizer vaccine offered to children aged five to 11 will be a lower dose that is safe and effective at protecting this age group from COVID-19 and the Delta variant. I strongly encourage every parent and caregiver to get their younger children vaccinated and protected.”
Achieving the highest vaccination rates possible is key to limiting the risk of transmission and protecting our hard-fought progress against COVID-19. Together with its partners the government continues its Last Mile Strategy to administer thousands of first and second doses to adults and youth already eligible for their shot as we also continue to provide booster doses to nearly three million eligible Ontarians.
At the beginning of this month, I had the pleasure of attending Obesity Week 2019 alongside a delegation of physicians from Obesity Canada. In the middle of the bustling Las Vegas strip, we hunkered down and immersed ourselves in the latest advancements in obesity research. From the TOS/WOF Joint Symposium on sugar consumption to the presentation of the Obesity Risk calculator from the team at the Cleveland Clinic, the future of the field proved bright. Despite the wide variety of topics covered over the course of the week, two specific points struck a chord with me, weaving themselves through every discussion and presentation. First, was the importance of the recognition of obesity as a chronic disease rather than a choice; and second, that weight bias poses one of the most difficult barriers to the treatment and management of obesity.
The recognition of obesity as a chronic disease with a defined pathology is a key milestone in the evolution and emergence of modern obesity treatment and management. Yet while obesity has been given “disease” status by the WHO, approaches to treatment have failed to evolve in tandem. Our traditional approach to care treats obesity as a risk factor rather than a disease, simplifying this complex and chronic condition to a case of exceeding the energy balance equation In the simplest terms: patients need to eat less and exercise more.
While exercise is an excellent way to improve your health, it does little to assist weight loss. And while a healthy diet is key to management, it fails to account for a broader range of factors that impact obesity. The science has shown that obesity isn’t a simple equation; it’s a multivariate system. Age, genetics, environment, emotional stability, sleep patterns, lifestyle and co-morbid diseases all play into disease progression. Consequently, physicians and clinicians need to take these factors into account when designing and implementing systemic approaches to treatment and management. We must focus on a holistic approach intended to improve the patients’ overall health and wellbeing, rather than simply focusing on weight loss.
One of the greatest barriers to this new system of care is obesity bias, or the negative attitudes and views about obesity, and the people that suffer from it. While obesity bias is most easily recognizable when it manifests as verbal or physical discrimination, it can present in a multitude of ways. From the lack of appropriately sized chairs in a doctor’s office to denial of healthcare affiliated costs by insurance providers, weight bias can have serious implications for patients’ well-being and may even lead to further weight gain. By perpetuating the traditional view of obesity as a self-inflicted condition rather than a biological disease, it redirects “blame” onto patients and creates negative associations with weight and self-care, resulting in a reduced efficacy of treatment and increasing the likelihood that patients will not seek out treatment.
So how can we, as physicians, combat obesity bias in our everyday practice? An easy first step is to revisit the language we use when discussing obesity. Many of my colleagues at Obesity Week 2019 advocate for the use of “people first language” to reduce stigma and avoid reinforcing negative attitudes around obesity. Initial studies from the Perelman School of Medicine looking at the implementation of this practice are encouraging, suggesting that patients are more likely to engage with healthcare providers about their weight. By avoiding defining patients by their disease, we can facilitate positive and productive discussions around weight and overall health, improving treatment outcomes and preventing the development of comorbid diseases.
Want to learn about a few more key takeaways from Obesity Week 2019? Check out these top ten highlights from our week in Vegas: https://bit.ly/2qvfXp6