As demand for the treatment known as the "miracle obesity drug" GLP-1 (Glucagon-Like Peptide-1) rises in the United States, insurance companies burdened by costs are increasingly reducing coverage. This has raised concerns that more patients are unable to obtain their medication on time or are abandoning treatment, which is shaking the entire U.S. healthcare system.
On the 25th (local time), The Washington Post (WP) reported that insurance companies are reducing coverage as the financial burden has significantly increased with GLP-1 treatments being used long-term by millions in the U.S. Originally developed to treat diabetes, GLP-1 treatments are prescribed for obesity due to their appetite-suppressing and weight-loss effects. Notable examples include Wegovy from Novo Nordisk and Zepbound from Eli Lilly.
According to WP, the monthly expense for GLP-1 medications amounts to about $1,000 (approximately 1,365,740 won) per person, prompting insurers to impose restrictions on prescription approvals or to cease coverage altogether. Medicare, the health insurance program provided by the federal government for seniors aged 65 and older and certain disabled individuals, also does not cover the use of GLP-1s for obesity treatment.
In particular, cost reductions are visibly apparent in insurance for public employees. The State Governments of North Carolina and Colorado have either already halted or announced plans to halt coverage for GLP-1 medications under the State Employee Health Plan, stating they "cannot bear the costs without doubling premiums."
According to market research firm IQVIA, 62% of prescriptions for GLP-1s for obesity treatment were denied by insurance companies last year, with the actual dispensing rate being only 28%. In contrast, the cash purchase rate surged from 11% in 2023 to 53% this year, significantly increasing the financial burden on patients.
In response, patients are coping through various means, such as appeals for prescription approval, low-dose self-adjustment, and direct sales with pharmaceutical company discounts, but confusion continues in the field. When CVS, the largest drugstore chain in the U.S., entered into a discount agreement with Novo Nordisk to prioritize the sale of Wegovy, patients using Zepbound transitioned to Wegovy, leading to reports of side effects.
Healthcare professionals are also expressing their struggles as they frequently change prescribed medications according to patients' insurance conditions and support complex approval processes, resulting in a surge of non-clinical tasks. Laura Davidson, a professor at West Virginia University, noted in an interview with WP that "now doctors are responsible for negotiating drug prices," expressing her fatigue.
Experts agree that while GLP-1 medications can contribute to improving public health, their excessively rapid spread and high-cost structure are placing serious burdens on both public and private insurance systems. In fact, Eli Lilly generated over $200 million (approximately 272.8 billion won) in revenue from patients with out-of-pocket expenses in the first quarter of this year, with one out of four new prescriptions not covered by insurance.
Jaime Almanza, a professor at the University of Texas Southwestern Medical Center, said, "The insurance environment is placing burdens on treatment teams," adding that "gaps in treatment among patients are widening."