June 3, 2023 / By

Unhealthy Limitations: Restrictions on Weight Loss Drugs and Diabetes Medications by Insurers and PBMs

Unhealthy Limitations: Restrictions on Weight Loss Drugs and Diabetes Medications by Insurers and PBMs

In recent years, there has been a growing concern regarding the increasing global prevalence of obesity and related diseases, such as Type 2 diabetes. Governments, healthcare providers, and pharmaceutical companies have made significant efforts to address this issue by developing and promoting weight management solutions. However, despite these efforts, insurers and pharmacy benefit managers (PBMs) are restricting access to weight loss drugs, including Novo Nordisk’s Wegovy and Saxenda, both approved for weight loss, as well as the diabetes drug Ozempic. This essay seeks to discuss why insurers and PBMs are restricting access to these drugs.

One of the main reasons why insurers and PBMs are restricting access to weight loss drugs is the cost. These drugs are often expensive, and the cost can be a significant barrier to access for many individuals. Health insurance providers and PBMs are always seeking ways to reduce costs, and one of the ways they do this is by limiting coverage for expensive medications. They may also require prior authorization before covering a drug, which can delay access for patients who urgently require weight loss medication.

Another reason why insurers and PBMs are restricting access to weight loss drugs is the lack of long-term safety data. Although many weight loss drugs have received regulatory approval, their long-term safety is yet to be fully established. The potential risks associated with the long-term use of these drugs include heart disease, psychiatric disorders, and cognitive impairment. Therefore, insurers and PBMs may be hesitant to cover these drugs without sufficient long-term safety data to rely on.

Additionally, insurers and PBMs may restrict access to weight loss drugs due to concerns about misuse or abuse. Many weight loss drugs are controlled substances, meaning they have the potential for abuse and dependence. Insurers and PBMs may restrict coverage for these drugs to prevent abuse and misuse and to ensure patients receive the drugs only under the supervision of a healthcare provider.

Finally, insurers and PBMs may restrict access to weight loss drugs due to the lack of evidence supporting their efficacy in achieving long-term weight loss. Weight loss drugs are typically intended to supplement diet and exercise, but the long-term effectiveness of such drugs remains unclear. Some clinical trials have shown that weight loss drugs can help individuals lose weight in the short term, but not everyone can maintain the weight loss over the long term. Insurers and PBMs may be hesitant to cover weight loss drugs when the evidence regarding their long-term effectiveness is limited.

Insurers and PBMs are restricting access to weight loss drugs such as Novo Nordisk’s Wegovy and Saxenda and the diabetes drug Ozempic for various reasons, including cost, long-term safety data, potential for abuse, and limited evidence regarding their long-term effectiveness. While these restrictions may limit access to weight loss medications, healthcare providers and pharmaceutical companies must continue to look for ways to address obesity and related diseases through alternative means, such as education and lifestyle interventions, to help patients maintain optimum health.