Tandra Cooper Harris and her husband, Marcus, who both have diabetes, have encountered difficulty in obtaining the prescriptions they require to regulate their blood sugar levels for the past year and a half.
Cooper Harris experiences amnesia, becomes too fatigued to supervise her grandchildren, and encounters difficulties in earning additional income by braiding hair in the absence of Ozempic or a comparable medication. Marcus Harris, a server at Waffle House, necessitates Trulicity to prevent contusions and edema in his lower extremities.
The couple’s physician has attempted to prescribe a similar medication that imitates a hormone that suppresses appetite and regulates blood sugar by increasing insulin production. However, these items are frequently unavailable. The couple’s Affordable Care Act marketplace insurance imposes an exorbitant out-of-pocket expense or an onerous approval process on certain occasions.
Cooper Harris, a 46-year-old resident of Covington, Georgia, which is located to the east of Atlanta, expressed his sentiment that he felt compelled to overcome obstacles in order to survive.
A substantial number of individuals with diabetes and obesity are unable to access the essential medications necessary to maintain their well-being due to insurance obstacles and supply constraints regarding this potent class of medications, known as GLP-1 agonists.
The exorbitant pricing established by pharmaceutical companies is one underlying factor that contributes to the issue. According to KFF poll results released this month, approximately 54% of adults who had taken a GLP-1 drug, including those with insurance, reported that the cost was “difficult” to afford. Nevertheless, patients with the lowest disposable incomes are experiencing the most severe repercussions. These people are resource-limited and struggle to afford medical care and nutritious foods.
In the United States, Novo Nordisk and Eli Lilly both charge approximately $1,000 for a one-month supply of Ozempic and Mounjaro, respectively. The Peterson-KFF Health System Tracker indicates that the cost of a month’s supply of various GLP-1 drugs ranges from $936 to $1,349 prior to insurance coverage. According to research conducted by KFF, Medicare expenditures for three prominent diabetes and weight loss medications—OOzempic, Rybelsus, and Mounjaro—totaled $5.7 billion in 2022, an increase from $57 million in 2018.
Sen. Bernie Sanders, an independent from Vermont who leads the U.S. Senate Committee on Health, Education, Labor, and Pensions, wrote to Novo Nordisk in April that the “outrageously high” price has “the potential to bankrupt Medicare, Medicaid, and our entire health care system.”
Furthermore, the medications’ exorbitant prices prevent them from being accessible to all individuals who require them. Wedad Rahman, an endocrinologist affiliated with Piedmont Healthcare in Conyers, Georgia, stated, “They are already somewhat disadvantaged in a number of ways, and this further disadvantages them.” Underserved individuals, those with high-deductible health plans, and those enrolled in public assistance programs such as Medicaid or Medicare, including Cooper Harris, are among the individuals who visit Rahman.
Numerous pharmaceutical companies provide patient assistance programs that enable individuals to initiate and sustain medication usage at minimal or no cost. However, these programs have been found to be unreliable due to supply shortages, with the exception of medications such as Trulicity and Ozempic. Moreover, the requirement that patients obtain prior authorization or attempt less expensive medications first contributes to treatment delays, as do the demands of numerous insurers.
A significant number of Rahman’s patients have been afflicted with uncontrolled diabetes for years before seeking her care, and they present with severe complications such as blindness or foot ulceration. Rahman declared, “Therefore, the road concludes at that point.” “I am compelled to select an alternative that is more cost-effective but less advantageous to them.”
Trulicity, Mounjaro, and Ozempic are GLP-1 agonists, a class of medications that were initially approved for the treatment of diabetes. There has been a substantial increase in demand for rebranded formulations of Mounjaro and Ozempic for weight loss in the past three years, as authorized by the Food and Drug Administration. Furthermore, the demand for the pharmaceuticals is on the rise as more of their advantages become apparent.
The FDA’s approval of Wegovy, a weight-loss drug that is a derivative of Ozempic, to treat heart conditions in March is expected to result in a rise in demand and expenditure. By 2030, J.P. Morgan, a financial services company, anticipates that up to 30 million Americans, or 9% of the U.S. population, will be using a GLP-1 agonist.
Pharmaceutical companies are encountering difficulties in manufacturing adequate quantities of GLP-1 agonists as an increasing number of patients request prescriptions.
Eli Lilly is advising individuals to refrain from using its drug Mounjaro for cosmetic weight loss in order to guarantee that there are sufficient supplies for individuals with medical conditions. However, despite the presence of adverse effects such as constipation and nausea, the drugs’ popularity continues to increase due to their effectiveness and celebrity endorsements. Oprah Winfrey aired an hourlong special in March that focused on the weight loss benefits of the medications.
Jody Dushay, an assistant professor of medicine at Harvard Medical School and an endocrinologist at Beth Israel Deaconess Medical Center, observed that it may appear that every individual on the planet is utilizing this category of medication. She stated, “However, the number of individuals is not as substantial as one might anticipate.” “There is absolutely no such thing.”
Patients and healthcare providers are compelled to navigate a complex labyrinth of coverage options, despite the availability of the requisite medications, as insurers are enforcing stringent regulations. The coverage of weight loss medications by state Medicaid plans varies. The pharmaceuticals are not covered by Medicare if they are prescribed for obesity. Additionally, commercial insurers are restricting access to the pharmaceuticals as a result of their high cost.
Healthcare providers are developing care plans that are consistent with the financial resources available to them and the financial capabilities of their patients. For example, Cooper Harris is insured for Trulicity, but Ozempic is not. She indicated that she prefers Ozempic because of its reduced adverse effects. Rahman reported that she was compelled to rely more on insulin rather than transitioning to Ozempic when her pharmacy ran out of Trulicity.
She stated that Brandi Addison, an endocrinologist in Corpus Christi, Texas, was compelled to modify the prescriptions of all eighteen patients under her care on a specific March day as a result of complications deriving from drug accessibility and expense. Addison reported that a GLP-1 agonist was unaffordable for a patient who was insured under a high-deductible teacher retirement health plan.
Addison declared, “She is unable to utilize that medication until she has met the deductible.” Nevertheless, her patient was prescribed insulin, which is priced at a fraction of the cost of Ozempic but does not offer the same benefits.
Addison declared, “Our most vulnerable patients will be those with fixed incomes.”
