Only 1% of ACA Marketplace plans cover GLP-1 drugs for obesity

In June 2024, the Peterson–KFF health system tracker published an article highlighting insurer strategies to manage costs associated with weight loss drugs, namely, glucagon-like peptide-1 receptor agonists (GLP-1 drugs). The tracker analyzed the formularies of Affordable Care Act (ACA) Marketplace plans, finding that less than 1% covered Saxenda and Wegovy, GLP-1 drugs with obesity indications, and 0% covered Zepbound.

Although most individuals with private insurance are sponsored through employers, the analysis notes that the employer plan formularies are not publicly available, so KFF decided to analyze private insurance sponsored by ACA Marketplace plans on their GLP-1 coverage. To date, Medicare does not offer coverage of GLP-1 drugs for weight loss, and Medicaid coverage varies depending on an individual’s state.

The cost of GLP-1 drugs has presented a significant challenge for insurers and patients. Although the exorbitant price tag means that most patients cannot afford the drug without insurance coverage, insurers note that covering these drugs is a highly costly undertaking.

Nearly all insurance plans have made some effort to manage the costs associated with these drugs. For some insurers, that means not covering the medications at all, while others use strategies to limit the number of patients who can take them.

For example, the health tracker states that among ACA Marketplace plans, 0% list  Zepbound on their formularies, and only 1% list Saxenda or Wegovy — the three FDA-approved GLP-1s for weight loss. Coverage for diabetes is significantly greater but still not complete. For example, 51% list Mounjaro on their formularies. Ozempic, Rybelsus, and Victoza have greater coverage at 83%, 76%, and 60%, respectively.

Beyond not covering the drugs, most plans that did list these drugs on their formularies used some sort of utilization management strategies to limit use. All plans that listed Wegovy, Sexenda, Victoza, or Rybelsus and nearly all that listed Mounjaro (98%) and Ozempic (99%) had a utilization management strategy.

Furthermore, all the plans that listed Saxenda and Wegovy required prior authorization, although none of them demanded step therapy. Additionally, 84% and 79% of plans set quantity limits for Saxenda and Wegovy, respectively.

For Ozempic and Mounjaro, 86% of plans required prior authorization, and 13% and 14% required step therapy. Quantity limits on Ozempic were set by 96% of plans, and 89% of plans set limits on Mounjaro. Rybelsus required prior authorization for 87% of plans, step therapy for 16%, and had quantity limits for 96%. Finally, Victoza needed prior authorization for 75% of plans, with step therapy and quantity limits for 24% and 97%.

“Utilization management tools are intended to balance cost control and access but may still pose barriers for people with a medical necessity to take these drugs. With such high demand for and short supply for GLP-1 agonists, some people have procured them from alternative sources, such as online vendors, medical spas, or compounding pharmacies selling products not evaluated by the FDA, some of which may contain different ingredients,” concluded the report.