Payers Consider Policy Options for Access to GLP-1 Obesity Medications

With up to 40% of the U.S. population potentially eligible for treatment with GLP-1 inhibitors for obesity, payers and policymakers and other experts question how they provide coverage that is affordable for patients, according to a new paper by the Institute for Clinical and Economic Review’s (ICER).

Sarah K. Emond

“The obesity medications Wegovy and Zepbound are fairly priced from a long-term value perspective at their current estimated net price,” Sarah K. Emond, president and CEO of ICER, said in an interview. “That means over a lifetime, the price will match the benefits that patients are going to receive.”

The impact on the healthcare system could be huge if the GLP-1 therapies could address the diseases associated with obesity. In fact, obesity is a factor in a wide range of illnesses (e.g., heart disease, stroke and arthritis) that can result in a cascade of costly pharmaceutical and medical treatments.

Affordable, however, is the shorter-term perspective on whether patients and the healthcare system can absorb the costs. With obesity medicines, the demand and the number of eligible patients are both high, and these drugs have high price tags.

The demand for GLP-1 drugs such as Wegovy and Zepbound for weight loss is increasing. A PwC survey in October 2024 found that 8% to 10% of Americans are currently taking GLP-1 drugs, and 30% to 35% of Americans are interested in using them.

Wegovy (semaglutide) was approved to treat obesity in June 2021, and it is available as a once-weekly, single-dose pen with a list price of $1,349. In March, Novo Nordisk began offering cash-paying customers a price of $499.

Lilly also lowered the prices of several doses of Zepbound (tirzepatide) for patients purchasing the obesity medication through the self-pay program. Zepbound is available for a list price of $1,059.87 a month.

“This is just the math,” Emond said. “We don’t have the money in our healthcare system unless it comes from somewhere else, so that's why we’re feeling this tension. That’s why some of these policy options probably don’t feel great, because they're not about necessarily providing broad access right away.”

Related: ICER Finds Insurers Struggled to Provide Fair Access for Obesity Drugs

Insurers have struggled to provide fair access for obesity drugs, according to ICER’s fourth annual Barriers to Fair Access assessment, which was released in December 2024. Many plans have policies in place for offering access to weight-loss drugs, but clients can opt out of that coverage

For many patients, accessing obesity medications through pharmaceutical companies’ direct-to-consumer option is costly at about $500 a month. “We’ll have a situation where only those with means get access to an effective and cost-effective medicine,” Emond said. “ I don’t think that’s the healthcare system we want.”

She said the concern is that this the access issue may not be solved until there are generics available for the GLP-1 therapies. “Sometimes I worry that we’re not going to figure this out until they go generic, and that in the meantime, we're going to have real equity issues about with who gets access.”

Policy Options for Obesity Drugs

ICER heard from employers, purchasers and health plans, as well as drug makers and patient groups, during the organization’s Policy Leadership Forum. This, along with a literature search, helped to inform the new paper that discusses potential policy solutions for the GLP-1 therapies for obesity.

Emond said it’s important to have discussions like this, not just about medications for weight loss. The pipeline for new drugs, she said, is full of potential therapies for diseases such as Alzheimer’s and liver diseases such metabolic dysfunction-associated steatohepatitis or MASH (formerly known as non-alcoholic steatohepatitis or NASH.)

“We have big eligible patient populations out there who are waiting for transformation similar to this [the weight loss drugs],” Emond said. “If we don’t figure out how we manage this affordability and access piece now, then we're going to fail patients later, when we get new medicine for other conditions.”

In the short-term, however, access to the GLP-1 therapies for obesity will likely continue to be limited to patients with higher BMI’s and those with comorbid conditions, with a requirement for life-style management, Emond said. Insurers may also cover a single drug, require step therapy or consider a carve-out program for obesity management.

“And although this is not likely, but I am sympathetic to the idea that the federal government could provide subsidies to commercial insurers and then expand their own access through its programs,” she said. “The Medicare program is what’s going to benefit from the cost savings that will come from having a healthier, older population if we're addressing obesity earlier.”

Going forward, Emond said ICER will be watching three developments, the first being the direct to consumer product and whether new drugs that come to the market to treat patients with obesity will have an impact on prices.

Additionally, she said it will be important to consider how CMS will handle the next set of drugs subject to Medicare Part D price negotiation. Novo Nordisk’s three semaglutide products — Wegovy; and Ozempic and Rybelsus, which both treat diabetes — top the list, which was released in January 2025.

ICER plans to host a public webinar at 12:00 pm ET on April 22, 2025, to discuss the potential market strategies and federal policy solutions outlined in the white paper.