{"id":13781,"date":"2026-06-09T05:36:34","date_gmt":"2026-06-09T05:36:34","guid":{"rendered":"https:\/\/medical-article.com\/?p=13781"},"modified":"2026-06-09T05:36:34","modified_gmt":"2026-06-09T05:36:34","slug":"why-dont-health-plans-voluntarily-cover-glp-1s-for-obesity","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=13781","title":{"rendered":"Why don\u2019t health plans voluntarily cover GLP-1s for obesity?"},"content":{"rendered":"<p>ICER found <a href=\"https:\/\/icer.org\/wp-content\/uploads\/2025\/12\/ICER_Obesity_Final-Report_For-Publication_121625.pdf#page=16.09\">GLP-1 drugs to be cost effective for treating obesity<\/a>.  If that is the case, why don\u2019t more US payers cover the GLP-1 drugs?  Clearly, one reason is the cost given the sheer volume of patients i nthe US that are obese; specifically, <a href=\"https:\/\/www.niddk.nih.gov\/health-information\/health-statistics\/overweight-obesity\">&gt;40% of US adults are obese<\/a>.  However, a bigger issue may be adverse selection.  <\/p>\n<p>Consider the case of the <a href=\"https:\/\/www.cms.gov\/priorities\/innovation\/innovation-models\/balance\" target=\"_blank\" rel=\"noopener\">Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth (BALANCE) model<\/a>, a voluntary model introduced by the Centers for Medicare and Medicaid Services (CMS) that would have provided drug coverage for GLP-1 drugs for obesity in Medicare and Medicaid.  In exchange for this generous coverage, drug manufacturers would drop their prices. Kenneth Thorpe and  Kirsten Axelsen write in a <a href=\"https:\/\/www.healthaffairs.org\/content\/forefront\/after-balance-why-voluntary-coverage-obesity-drugs-failed-and-comes-next\">recent <em>Health Affairs Forefront <\/em>article<\/a> that within the BALANCE model:<\/p>\n<p> Manufacturers of the FDA approved GLP-1s in BALANCE, Eli Lilly and Novo Nordisk, would have dropped GLP-1 treatment net prices to CMS to\u00a0<a href=\"https:\/\/www.whitehouse.gov\/fact-sheets\/2025\/11\/fact-sheet-president-donald-j-trump-announces-major-developments-in-bringing-most-favored-nation-pricing-to-american-patients\/\" target=\"_blank\" rel=\"noopener\">$245 per month<\/a> for all presentations, including obesity. However, an insufficient number of prescription drug plans agreed to participate. <\/p>\n<p>However, it\u2019s voluntary nature was problematic, due to adverse selection:<\/p>\n<p><em>From this outcome [few Part D plans participating in BALANCE], one thing is clear: Voluntary coverage for obesity drugs, even at government-set drug prices, does not work\u2026<\/em> <br \/>Dropping drug prices didn\u2019t solve the systemic problem. Plans that would have joined the pilot would attract beneficiaries with obesity whose\u00a0<a href=\"https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC10394178\/?__hstc=201281073.57fd49657016f2aa567d9cd087c2f108.1779482014498.1780505071893.1780590902156.6&amp;__hssc=201281073.2.1780590902156&amp;__hsfp=fffcae3bc6202406ddeeb299800f3a23\" target=\"_blank\" rel=\"noopener\">medical costs are twice as high<\/a>\u00a0as those without obesity, leading to higher premiums that could scare off healthier enrollees. It is unclear how much premiums would change with GLP-1 coverage for obesity, as drug plans are\u00a0<a href=\"https:\/\/onlinelibrary.wiley.com\/doi\/full\/10.1002\/oby.23973?casa_token=wR-KPhX4bZoAAAAA%3AVSAZfm3PcvhJ-URyK5l9WTdKrI40k18fbmA5SPNhss0GlCEG-v5YgJchpXePLKeD8u7Uv0vMCWkugQq9\" target=\"_blank\" rel=\"noopener\">getting discounts on GLP-1s<\/a>\u00a0for other uses and indications prior to BALANCE. <em> <\/em> <\/p>\n<p>The <a href=\"https:\/\/www.healthaffairs.org\/content\/forefront\/after-balance-why-voluntary-coverage-obesity-drugs-failed-and-comes-next\">Thorpe and Axelsen article<\/a> argues that CMS should remove restrictions on coverage of obesity medications; the articl is interesting throughout. You can find <a href=\"https:\/\/www.kff.org\/medicare\/what-to-know-about-the-balance-model-for-glp-1s-in-medicare-and-medicaid\/\">more information on the BALANCE and GLP-1 Bridge programs<\/a> on the KFF website as well.<\/p>","protected":false},"excerpt":{"rendered":"<p>ICER found GLP-1 drugs to be cost effective for treating obesity. If that is the case, why don\u2019t more US payers cover the GLP-1 drugs? Clearly, one reason is the cost given the sheer volume of patients i nthe US that are obese; specifically, &gt;40% of US adults are obese. However, a bigger issue may&#8230;<\/p>\n","protected":false},"author":0,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-13781","post","type-post","status-publish","format-standard","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/13781"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=13781"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/13781\/revisions"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=13781"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=13781"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=13781"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}