Anthem has used the same language in other letters to clinicians in New York and North Carolina, confirmed by The Washington Post, and the eerie tone revolves around a new drug that could upend obesity treatments. It suggests that a collision is imminent.
The drug, often called GLP, is fueling a patient frenzy and a pharmaceutical industry gold rush. However, its high price and the huge population that could potentially benefit from it pose a challenge for insurers.
While insurers appear to be tightening up their rules to prevent off-label prescribing for now, Ozempic and similar drugs have a wide range of health benefits associated with weight loss, namely cost savings for insurers. Things can change if something is shown.first such result major research It is scheduled for later this summer.
Only in Ozempic Regulatory approval It is for diabetes but contains the same active compound, semaglutide, as another drug approved for obesity. we goby. Doctors order Ozempic to treat obesity because many insurance companies don’t cover weight-loss drugs, a practice known as “off-label” prescribing common across medicine.
“There’s really no difference between semaglutide as Wegobee and semaglutide as Ozempic,” said Angela Fitch, president of the Obesity Medical Association and co-founder of weight-focused startup Knowwell. Stated. She has seen some of Anthem’s letters, but she believes they are unjustified, saying, “These clinicians have not committed any fraud.”
Less than 150 health care providers received the letter, according to Elevance Health, which runs the Anthem Plan. Insurers said doctors could still prescribe Ozempic, although in most cases Ozempic would not be covered unless the patient had been diagnosed with diabetes and had tried another drug to manage it. “A significant increase in off-label prescriptions is causing shortages nationwide,” the letter said, and diabetics “often cannot find medicines in stock.”
America’s Health Insurance Plans, an industry group, has raised concerns about GLP’s side effects and costs. “The evidence about how these drugs affect obesity-related complications such as heart disease and diabetes is still evolving,” spokesman David Allen said.
There may be no drug on the market that is getting more buzz than GLP. These are popularized by celebrities, go viral on social media, and change the lives of people who have tried everything to lose weight for decades. They are also creating windfall profits for pharmaceutical companies large and small, disrupting the fortunes of traditional weight-loss companies, and fueling the growth of companies that manufacture the components needed to inject drugs.
GLP is very popular and has been compared to cultural touchstones like Botox and Viagra, but it has the potential to appeal to a wider patient population and over a longer period of time. Pfizer estimates that the GLP market could be worth: $90 billion annually Up from $25 billion by 2030.
New prescriptions for Novo Nordisk’s Ozempic and Wegoby jumped 140% and 297%, respectively, a year ago, according to research notes from Cowen analysts.List price is over $900/month and GLP is much more expensive than the old one Some insurers are asking patients to clear more hurdles before coverage, according to several doctors who treat obese patients.
The American Centers for Disease Control and Prevention 40 percent of adults People over the age of 60 are obese. At this rate, treating just 10% of Medicare beneficiaries with her Wegovy could cost him $26.8 billion a year, one study said. Recent analysis. (Federal law would need to change to allow Medicare to cover weight loss drugs).
Demand is so high that Novo Nordisk announced in early May that it would cut demand. Wegovy Dosage Supply To save medication for patients already taking it for new patients.
In March, a little-known biotech company called Viking Therapeutics small early stage trial This is comparable to GLP already on the market. Viking’s stock price doubled in one month, adding $1.4 billion to its stock market value. This is a surprising rise for such preliminary findings.
Last month, it was Pfizer’s turn to ride the weight loss wave.rear Publication Confirmed Earlier disclosure of the performance of one of its GLP drugs sent the pharmaceutical giant’s share price skyrocketing, adding more than $10 billion to its value. “We are clearly in the prime of GLP,” said Evercore ISI analyst Umar Rafat, when investors are betting that kind of money on drugs that may not even make progress. writing in a notebook.
Approved by the Food and Drug Administration, GLP was an instant source of funding for developers. Eli Lilly generated $568.5 million in revenue in the first three months of 2023 from its new diabetes drug, Mounjaro. Danish company Novo Nordisk reported that combined sales of Ozempic and Wegoby were worth about $3.5 billion over the same period.
Developing drugs that help people lose weight meaningfully and safely has been the pharmaceutical industry’s “holy grail” for decades, analysts say. The new drug is a man-made version of glucagon-like peptide 1, which is produced naturally by the body to help regulate blood sugar levels, make food pass through the stomach more slowly, and suppress appetite. Hormones. The treatment has evolved from a daily injection to once-a-week dosing, and drug companies are developing tablet versions.
One of the hopes for these new drugs is the broader health benefits and potential cost savings that come with them. Matthew Gilbert, an endocrinologist at the University of Vermont Medical Center, said GLP drugs are so effective in managing diabetes that patients can be prescribed less insulin.
However, once the patient stops taking the GLP drug, the benefits of the GLP drug may be lost, and the patient may be on the GLP drug for the rest of their lives. Gilbert said he wasn’t worried about long-term safety, but the prospect of lifetime use raises questions that no one has yet answered. “Are these drugs safe for a man to take for his 30 years?” he said.
Weight Watchers International’s chief executive warned that the drug was “not a magic pill,” but the company’s shares soared 59% the day after the announcement. completed the transaction This will allow GLP drugs to be sold directly to patients.
Weight Watchers Chief Scientific Officer Gary Foster said in a statement that while GLP is groundbreaking, it needs to be combined with a behavioral program. That “is the foundation for healthier eating and activity patterns and a better quality of life,” he said.
The cost and difficulty of finding GLP has spawned extensive marketing efforts by companies seeking to capitalize on the drug’s popularity.
Arizona-based telemedicine company Shed Rx, founded in January, advertises:affordable tirzepatideFor an initial cost of $499/month, Munjaro list price, the only tirzepatide drug approved by the FDA. The company’s CEO, Morley Baker, says the company is able to do this because it orders from dispensing pharmacies, and the prices are lower than branded versions.
“People are looking for affordable solutions,” Baker said. He has no healthcare experience himself, but his partner does.
FDA only allows dispensing pharmacies to manufacture over-the-counter products when there is a shortageas in the present case, tirzepatide and semaglutide.agency recently warned The company said it “received reports of adverse events after patients used combined semaglutide,” and said patients should use FDA-approved drugs when possible.
Baker did not respond to subsequent requests for comment.
Ozempic made a huge impact on Barbara Senich, 66, from North Carolina, and Londalyn Ware, 59, from Texas. They both struggled with weight most of their lives, tried numerous diets and underwent bariatric surgery before trying Ozempic.
“I went from feeling like I was on the edge of a cliff, like a hopeless person, to now feeling like I have control over this,” says her struggle with weight, which began in fourth grade. Senich, a former pharmaceutical company executive, said.
Ware, who works as an accountant, said her weight-loss success at Ozempic was “unlike anything I’ve done before.”
But this is where their experiences diverge. Senich has been diagnosed with pre-diabetes and is covered by insurance. Ware is not.
After Ware’s insurance cut Ozempic coverage, she tried one drug after another until she was prescribed Munjaro. Munjaro is a GLP drug that is approved for diabetes but is also prescribed off-label for the treatment of obesity. This was a big change for clothing that can be purchased for $25/month through coupons from manufacturer Eli Lilly. Still, I’m having trouble finding a pharmacy that accepts coupons.
“I went to chain pharmacies, small independent pharmacies, and out of state,” Ware said.
Some health plans, such as the Texas Teachers’ Retirement Plan, cover weight-loss drugs like Wegobee. obviously wrong. A letter the system sent to the Society of Obesity Medicine last month said the system had recently found an increase in its members using such drugs, but the drugs were excluded from benefits.
The letter states that “it was not the intention of TRS to provide insurance for weight loss or anti-obesity drugs,” and that if it does so, “TRS will fully cover the cost of such drugs within the plan.” We need to factor that into the premiums we charge our employees,” he added. .
American Medical Association Obesity is recognized as a disease Treatment began in 2013, but that treatment is still shaped by stigma. The condition has historically been viewed as a lifestyle, diet, and willpower issue, and many insurance plans exclude it along with cosmetic ailments such as hair loss. Some insurance companies cover his off label use of GLP medications, but many do not.
“The ‘eat less, move more’ approach is not very effective for the average person seeking meaningful and sustained weight loss,” says Jaime, medical director of UT Southwestern Medical Center in Dallas. says Armandos.
Armandos said Lilly last year had coupons for Munjaro available to anyone with commercial insurance, regardless of whether they had diabetes. In addition to it, Studies on tirzepatide Last summer’s dramatic weight loss in obese, non-diabetic patients “led to a significant increase in off-label prescriptions,” Armandos said.
Now, he and other doctors have noticed that insurance companies tend to require additional steps and paperwork, such as asking people to try other cheaper weight-loss drugs first before reimbursing GLP.
Tahel Modalessi, a physician at the Hamilton College of Cardiology in New Jersey, has not experienced such a tightening of requirements, but sees a conflict as imminent. It’s the doctor’s job to do what’s medically right for the patient, such as prescribing GLP drugs to treat obesity, he said. Yet, if such drugs were to be prescribed to everyone who qualifies, “we would face exorbitant systemic costs.”
He sets precedent by arguing that the price of GLP needs to be lowered rather than limiting treatments. Amgen, Sanofi and Regeneron slashed the price of its anti-cholesterol drug in 2018 in a bid to increase usage. “This is an approach worth serious consideration,” he said.
