Who gets Ozempic? People with private insurance and generous health plans, study shows
The demand for popular prescription drugs that treat diabetes, obesity and heart disease has skyrocketed over the past few years. New research from the University of Southern California showed a 442% increase in prescriptions for semaglutide between January 2021 and December 2023. Semaglutide is the active ingredient in diabetes drugs Ozempic, Rybelsus and Wegovy, a heart disease prevention and weight-loss drug.
As the list of medical uses for these drugs continues to grow, patients are experiencing more difficulty getting their insurers to cover these prescriptions that can cost over $10,000 a year. In fact, patients covered by Medicaid and Medicare represent a small share of those who've had their Ozempic and Wegovy prescriptions filled.
The USC study published this month in JAMA Health Forum sheds light on the disparities Medicaid and Medicare holders face when trying to access these blockbuster anti-obesity and diabetes drugs.
"If only certain patient populations get access to these medications — those primarily with private insurance, more generous health plans — then there's a huge percentage of the U.S. population that isn't getting access to these medications," lead author Christopher Scannell told Axios.
Here's what you need to know about patient access to Ozempic, Rybelsus and Wegovy:
Privately insured patients more likely to have their prescriptions filled
Many private insurers and government-funded Medicare and Medicaid typically don't cover these drugs for weight loss, leaving them out of reach for significant numbers of people who want them. Some insurers have imposed requirements such as prior authorization or step therapy, which mandates that people try less expensive drugs first.
For those who are covered, patients with private insurance represented 90% of prescription fills for Wegovy in December of 2023, according to data from IQVIA's National Prescription Audit Payer Trak. Patients with Medicare Part D plans represented 1.2% of prescription fills during that same time period.
Less than 1% of prescription fills went to people paying in cash, the study found.
Medicare, the federal health program for adults 65 and older, is prohibited by law from covering drugs for the more than 2 in 5 Americans who are obese but otherwise do not have serious risk factors. Ozempic is only FDA approved to manage blood sugar levels and treat those with Type 2 diabetes - it's not yet approved for weight loss.
The nonprofit health policy organization KFF estimates that 1 in 4 Medicare enrollees who are obese may be eligible for Wegovy to reduce their risk of heart attack or stroke.
Federal spending on weight-loss drugs surges
A KFF analysis found Medicare spending on three drugs − Novo Nordisk's Ozempic and Rybelsus and Eli Lilly's Mounjaro − surged from $57 million in 2018 to $5.7 billion in 2022. That figure did not include rebates or other discounts negotiated by pharmacy benefit managers.
Federal spending on these drugs is likely to grow, experts say. If just 1 in 10 eligible adults take Wegovy to prevent heart attack or stroke, KFF estimated it would cost Medicare's Part D prescription drug coverage nearly $3 billion each year.
These weight loss drugs can cost patients around $1,350 a month, but research suggests they cost just $22 to make, Paste BN previously reported.
Contributing: Ken Alltucker, Karen Weintraub, Paste BN