The Problem with Health insurance, Pricing, and GLP-1s: Q&A with Whitney Stidom

The demand for GLP-1s may be high, but so are the prices. Whitney Stidom, vice president of consumer enablement at eHealth, spoke with Pharmaceutical Executive about how regulatory updates and insurance providers are impacting this issue.

Pharmaceutical Executive: What policy changes in the next two years could make GLP-1 drugs more accessible? How will the current administration’s efforts impact GLP-1 prices for weight loss?
Whitney Stidom: The Trump Administration is taking steps to make GLP-1s more affordable for millions of Americans, including for people both and with and without insurance. Through the launch of TrumpRx.gov and coverage changes being phased in for Medicare and Medicaid beneficiaries during the next few years, the Trump Administration is prioritizing more affordable access to GLP-1s medications, including for people seeking to use these medications to treat obesity and support weight loss.

PE: Why are GLP-1 medications for diabetes more likely to be covered by employer plans than GLP-1 for weight loss?
Stidom: GLP-1 drugs were originally developed to treat type 2 diabetes, so coverage of these medications to treat this condition is relatively common compared to for weight loss. In fact, 55% of employers cover GLP-1s for diabetes, but just 36% of companies cover these drugs for weight loss.

While GLP-1s are proving effective at promoting weight loss, at least for as long as the medications remain in use, many employers have been hesitant to extend coverage to individuals who are overweight. Cost is likely a significant concern, as expanding coverage of GLP-1s for weight loss would result in higher premiums due to the increased size of the eligible population.

Plus, research shows that up to 70% of people who start taking a GLP-1 stop within the first year. Given that discontinuation rate, some employers may be concerned that covering GLP-1s will cause a spike in premiums costs without a corresponding improvement in well-being or a reduction in healthcare costs through better prevention or management of health issues. Given that, some employers that are covering GLP-1s for weight loss are requiring individuals to also enroll in lifestyle coaching programs, which are designed to encourage improved nutrition and exercise habits to support long-term well-being.

PE: What can Medicare, Medicaid, and ACA enrollees expect for GLP-1 coverage?
Stidom: For Medicare and Medicaid beneficiaries, GLP-1 drugs are generally covered for the treatment of certain chronic conditions. For instance, 98% of Medicare Advantage plans cover at least one GLP-1 drug for the treatment of diabetes. Coverage for weight loss is far less common, with fewer than 1% of Medicare Advantage plans offering that.

Moving forward, the Trump Administration is seeking to expand access to GLP-1 drugs for individuals with Medicare and Medicaid coverage. Starting later this year and continuing into 2027, the monthly cost of certain GLP-1s will be less than $245 for Medicare and Medicaid enrollees, with Medicare beneficiaries potentially paying a co-pay of just $50 per month.

Similar to Medicare and Medicare, people enrolled in ACA plans will often have coverage of GLP-1s for the treatment of diabetes, but less so for weight loss. More than 90% of ACA plans include GLP-1 coverage for diabetes; when it comes to weight loss, just 3% of such plans include coverage.

PE: How can cash-paying consumers evaluate DTC prices?
Stidom: While 92% of Americans have health insurance, approximately 27 million people lack coverage. For people in that situation, the Trump Administration is taking steps to make it more affordable to access GLP-1s through TrumpRx.gov.

The new site offers certain types of GLP-1 drugs with monthly prices that average $350 and as low as $199, depending on dosage. That compares to previous monthly prices of over $1,000. For people without insurance, this is among the most affordable ways to access a GLP-1 for weight loss or the treatment of chronic conditions such as diabetes.