A new weight loss drug can become the best selling drug of all time. Who can afford it?

Eli Lilly drug if approved weight loss it may be the best-selling drug of all time, but there are growing concerns about who can actually afford it.

Experts are confident that the drug, called tirzepatide, will be approved by the Food and Drug Administration sometime next year. If that is the case, it will join two other popular – and expensive – recently approved weight loss drugs on the market, Ways and Saxenda, from drugmaker Novo Nordisk.

Annual sales of tirzepatide could fall to $48 billion, according to an estimate from Bank of America analyst Geoff Meacham. Another Wall Street analyst, Colin Bristow at UBS, estimated that the drug will reach $ 25 billion in annual sales – a figure that exceeds the record $ 20.7 billion set by the AbbVie’s rheumatoid arthritis drug Humira in 2021.

Kelly Smith, a spokeswoman for Eli Lilly, declined to say how much tirzepatide costs. Outside experts say the drugmaker could be on par with Wegovy, which carries a list price of about $1,500 for a month’s supply, and Saxenda, which price is about $1,350 for a month’s supply.

If the FDA approves the drug’s effectiveness, a “reasonable” price for tirzepatide could be about $13,000 annually, or about $1,100 a month, said Dr. David Rind, the chief medical officer for the Institute for Clinical and Economic Review, a research group that helps determine reasonable prices for drugs.

Medicines have been shown in clinical trials to be very effective for weight loss. All three drugs – given as injections – work in a similar way: They are a class of drugs called GLP-1 agonists, which mimic a hormone that helps reduce food intake and appetite. .

However, Eli Lilly’s tirzepatide also stimulates a second hormone, called GIP, which in addition to reducing appetite, can also improve the way the body breaks down sugar. and fat.

A phase 3 clinical trial found that a high dose of tirzepatide helped patients lose 22.5% of their body weight on average, or about 52 pounds, more than any drug on the market. A lot patients in court had a body mass index, or BMI, of 30 or more. In experiments, Wegovy and Saxenda reduced body weight by about 15% and about 5%each one.

Are weight loss pills covered by insurance?

At low doses, all three drugs have been proven to treat diabetes.

  • Tirzepatide is sold under the brand name Mounjaro for diabetes.
  • Semaglutide, when sold for weight loss, sold in a high dose and called Wegovy; at a lower dose, it is marketed for diabetes and sold as Ozempic.
  • Likewise, a high dose of the drug liraglutide is sold under the name Saxenda for weight loss, and in a low dose, sold as Victoza, for diabetes.

With the exception of Mounjaro, which was approved earlier this year, versions of the drugs used to treat diabetes are covered by most insurance plans.

It does not always happen when prescribed for obesity.

Obesity carries a unique brand, said Dr. W. Scott Butsch, director of toxicology at the Bariatric and Metabolic Institute at the Cleveland Clinic. Most doctors, he said, still see it as a moral problem rather than a medical one.

That belief — in addition to older anti-obesity drugs that don’t work very well — has made insurers reluctant to cover many new treatments, he said.

“You have a bias,” Butsch said, adding that insurance companies ask for more evidence of the benefits of anti-obesity drugs than they do for other types of drugs.

Some insurers may choose one of the weight-loss drugs and offer coverage, he said, but they often limit access only to patients who meet a certain threshold, such as a higher BMI. at 30.

What’s more, Butsch said, not everyone responds equally to any weight loss medication. If the drug covered by insurance doesn’t work for that patient, there are usually no other drugs left, he said.

Dr. Holly Lofton, director of the weight management program at NYU Langone Health, often prescribes new drugs to her patients but many, she said, are not covered by their insurance. “Patients tell me that it seems to them like insurance companies want to wait until they are sicker and more in need of a drug,” he said.

According to Lofton, some of his patients will end up spending thousands of dollars out of pocket for drugs for several months while they negotiate with their insurance to get coverage. Patients often don’t get reimbursed by their insurance plans for the money they’ve already spent on drugs, he added.

Said Dr. Fatima Stanford, a doctor who specializes in obesity and director of the endocrine division at the Massachusetts General Hospital in Boston, private insurance for obesity drugs is spotty, and treatment is often limited to the most expensive plans.

Does not cover Medicare. Antibiotics are not a Medicaid mandate, although some states have chosen to include them, he said.

Obesity is considered a chronic disease, and like other chronic diseases, many patients are expected to take medication for the rest of their lives – a huge financial burden if forced to pay out of pocket, Stanford said.

Only people who can afford a drug like tirzepatide alone, he said, will become “very rich.”

Despite the barriers to access, UBS analyst Bristow said he still expects tirzepatide to become an anti-obesity drug, noting that the U.S. supply is seen to be in short supply for medicine such as diabetes injections.

“The demand is clearly strong,” he said.

What should be replaced?

Lofton, of NYU Langone Health, said that drug insurance cannot be improved until more people in the medical field change the way they see obesity. It’s not something that can be fixed by diet, exercise or strength – instead, it’s a malfunction of the fat cells in the body, he said.

Prejudice and stigma about obesity are pervasive in the medical community.

“It’s clear to all health professionals, including doctors, nurses, nutritionists and others,” said Lisa Howley, a physician educator and the Association of American Medical Colleges’ senior director of policy and policy. partnership.

A review was published last year in the study journal Obesity found that health care professionals are suppressing and / or showing weight prejudice towards people with obesity.

But changing the minds of doctors – and with it, insurance companies – is very difficult. Requiring prescription drugs to be covered by insurance may require legislation, Stanford said.

In 2021, lawmakers announced it in the House of Representatives The Obesity Treatment and Reduction Act, which would have allowed the federal government to expand Medicare Part D to include anti-obesity drugs. The law had 154 co-sponsors, according to Congress.govbut did not receive a vote on the floor of the House before the end of the term.

American Health Insurance Plans, or AHIP, a trade group representing insurance companies declined to say whether it would support insurance coverage of tirzepatide if the drug wins FDA approval next year. or other antibiotics.

“Health insurers often evaluate the evidence for drugs and specific treatments for obesity, and they offer a wide range of options to patients – from lifestyle changes and dietary advice to in surgery with drugs,” said David Allen, a spokesman for AHIP.

Butsch, of the Cleveland Clinic, said he hopes insurance companies will cover tirzepatide.

“We’re really seeing for the first time really effective anti-obesity drugs,” he said. “Good luck is real.”

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