Diabetic Drugs Used to Help With Weight Loss Gain Popularity at Cost to Medically Necessary Patients
If you follow any type of celebrity news, there’s a good chance you’ve seen the words Ozempic, Wegovy or Mounjaro used. These specialty drugs were originally developed to treat Type II diabetes, but in the last year all three have gained popularity outside of their original use — in Hollywood and across the U.S. Prescriptions for Ozempic tripled from 2021 to 2022, causing shortages — and there have been upticks in the prescriptions for the other medications as well.
While these drugs can drastically help those struggling with their weight, they are still only covered by insurance if a doctor deems them medically necessary. Those looking to shed a few pounds can still get a prescription, but it won’t be covered by insurance.
Coverage or no coverage, they are still expensive. GoodRx estimates that 1 carton of Ozempic can cost anywhere from $973 to over $1,000. Manufacturers of these drugs do offer coupons to help offset their cost, advertising that for those who qualify under a medically necessary reason, the drug can cost as little as $25 a month.
However, as the popularity of these drugs continues to rise, manufacturers seem to be taking notice at the profits to be gained – putting those using the drug for medically necessary reasons at financial risk.
Our advocacy team has seen examples of how manufactures utilize vague language in their promoted coupons, giving them the option to expire the coupon and raise the price of their drug at any time – for anyone.
Below is an example of a manufacturer’s policy statement for a drug coupon that was recently revoked, forcing a medically necessary client to pay upward of $400 per month for their medication that had previously been only $25 – but was up charged without warning, as the coupon states the manufacturer has a right to do.
“MONTHLY AND ANNUAL MAXIMUM SAVINGS: For patients with commercial drug insurance coverage for [drug]: You must have commercial drug insurance that covers [drug] and a prescription consistent with FDA-approved product labeling to pay as little as $25 for a 1-month, 2-month, or 3-month prescription fill of [drug]. Month is defined as 28-days and up to 4 pens. Card savings are subject to a maximum monthly savings of up to $150 per 1-month prescription, $300 per 2-month prescription, or $450 per 3-month prescription fill and separate maximum annual savings of up to $1800 per calendar year.
Subject to [manufacturer] right to terminate, rescind, revoke, or amend Card eligibility criteria and/or Card terms and conditions which may occur at [manufacturer] sole discretion, without notice, and for any reason, Card expires and savings end on 12/31/2023.”
As demand for these drugs rise, manufacturers can fall back on the vague language in their coupons to raise prices for everyone without warning, and there is nothing patients or carriers can do.
If you are prescribed any of these drugs for a medically necessary condition and have noticed a significant increase in their price, we suggest the following:
Call your benefits advocate (if you have one) and let them know about the increase. They will conduct research on both the drug’s cost, your plan details, and any possible solutions.
Check your formulary for the drug’s coverage amount and tier
Utilize sites like GoodRx, SingleCare, or the manufacturer’s website for coupons or copay assistance.
If you are a Caravus Client and have experienced an increase in the cost of these or similar medications, please reach out to the Caravus Client Advocate.