More Patients Potentially Eligible for GLP-1 Drug Coverage
FDA clinical criteria at odds with more restrictive insurer standards
By Bruce Japsen
At least two in five U.S. adults—or more than 57 million people—under the age of 65 with “private insurance could be eligible under clinical criteria for GLP-1 drugs,” according to KFF.
In a new analysis, KFF, formerly the Kaiser Family Foundation, said that 42% of U.S. adults could be covered by health insurers if they are treated for “type 2 diabetes, obesity, or excess weight and weight-related health issues.”
“Though only about 3% of adults with employer coverage had a prescription in 2022, demand for and spending on GLP-1 drugs has grown and could continue to grow,” KFF said in its analysis. “Given the steep costs and high demand for these drugs, employers and insurers may continue to impose more restrictive eligibility standards for coverage than the clinical indications set by the FDA. Many private plans manage the costs associated with GLP-1 drugs by only covering them for diabetes treatment and not for weight management.”
Most employees and others with private health insurance coverage will first see what they will pay in premiums and co-payments this fall when they look at their 2025 benefits during the annual open enrollment, a period that runs from late September into early December when workers can choose or change their health benefit choices. They will also notice the kinds of restrictions health plans will place on whether they can even get their GLP-1 drugs paid for, analysts say.
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