An Eli Lilly & Co. Zepbound injection pen, set up in the Brooklyn borough of New York, USA, op … [+]
At least two in five U.S. adults – or more than 57 million people – under age 65 with “private insurance” could qualify for GLP-1 drugs based on clinical criteria. as shown by a new analysis.
KFF, formerly known as the Kaiser Family Foundation, said that 42% of American adults could be covered by health insurers if they are treated for “type 2 diabetes, obesity, or overweight and weight-related health problems,” according to a new KFF analysis.
“While only about 3% of adults with employer coverage had a prescription in 2022, demand and spending on GLP-1 medications have grown and may continue to grow,” KFF said in its analysis. “Given the high cost and high demand for these drugs, employers and insurers may continue to impose more restrictive participation standards for coverage than the clinical indications established by the Food and Drug Administration. Many private plans manage the costs associated with GLP-1 medications by covering them only for the treatment of diabetes and not for weight management.”
Yet these drugs, including Wegovy, Rybelsus and Saxenda – along with Ozempic and Zepbound – will be the “largest driver” of healthcare costs for employers, adding 1% to total premium spending by 2025. new data from the benefits consultancy Aon.
The KFF analysis tells a similar story that policymakers, employers and patients should brace themselves for, the report authors indicate. KFF cited annual filings with state regulators for the 2025 healthcare coverage year, saying: “Some insurers cited an increase in the use of GLP-1 drugs as a contributor to rising premiums.”
Most workers and others with private health insurance will first see what they’ll pay in premiums and co-pays this fall when they review their 2025 benefits during open enrollment, the annual ritual through which employees can choose or change their health benefit choices. . They will also notice the restrictions health plans will place on whether they can even get paid for their GLP-1 drugs, analysts say.
“Lots of ACA marketplaces plans manage costs associated with GLP-1 medications by covering them only for the treatment of diabetes and not for weight management,” KFF said of individual coverage under the Affordable Care Act, also known as Obamacare.
“These broad estimates indicate the potential number of non-elderly adults who meet clinical criteria for GLP-1 drugs, although employers and insurers may have more restrictive eligibility standards for coverage,” KFF’s analysis said. “Additionally, not all people who meet these clinical criteria would use GLP-1 medications, as many people with diabetes or obesity can manage their condition with diet, other medications and therapies, or choose not to seek treatment. ”