Reasonably priced Care Act (ACA) Market plans hardly ever cowl GLP-1 medication authorized solely for weight problems remedy, in accordance with a new KFF analysis of 2024 federal plan knowledge. Wegovy, a drug that’s authorized for weight reduction, is roofed by simply 1% of Market prescription drug plans, in comparison with 82% of Market prescription drug plans for Ozempic, which comprises the identical lively ingredient as Wegovy (semaglutide) however is authorized just for diabetes.
When GLP-1 medication are coated for diabetes remedy, virtually all plans use no less than one utilization administration technique to regulate prices, corresponding to prior authorization or amount limits. Of the few Market plans that cowl GLP-1 medication authorized for weight problems, all require prior authorization.
Utilization administration instruments are supposed to steadiness price management and entry however should pose boundaries for individuals with a medical necessity to take these medication. Whereas insurers obtain rebates to offset a few of their prices, the record costs of GLP-1 medication are about $1,000 per thirty days, and rising demand for these medicines might put upward strain on premiums.
This evaluation examines publicly out there formularies of plans out there on the federally facilitated ACA Marketplaces in 2024 and doesn’t embody states that run their very own Marketplaces, the place protection patterns might differ. The ACA Marketplaces symbolize a small share of individuals with non-public medical insurance, as most individuals with non-public protection have plans sponsored by their employers. Whereas info on employer plan formularies will not be publicly out there, these plans could also be extra more likely to cowl medication for weight reduction than ACA Market plans given the will to draw employees, although they might make use of related utilization administration methods.
