GLP-1 Access: What Clinicians Need to Know and What RDNs Want to Understand, Pt. 1
This episode of Nutrition411, the podcast, delves into the challenges of accessing GLP-1 medications, focusing on insurance coverage issues and the high costs of out-of-pocket expenses. Bonnie Chambers, MSN, FNP-C, a family nurse practitioner specializing in metabolic health, discusses the hurdles patients face, such as some insurance plans not covering GLP-1s, and the complex criteria for coverage that often do not align with clinical indications.
This episode highlights the frustration of patients who are misled by advertisements and insurance communications, leading to confusion and unmet expectations. Chambers emphasizes the importance of healthcare providers as resources to help patients navigate these barriers, despite the often inconsistent and misleading information provided by insurance companies.
Transcript:
Lisa Jones, MA, RDN, LDN, FAND: Hello and welcome to Nutrition411, the podcast, where we communicate the information that you need to know now about the science, psychology and strategies behind the practice of dietetics. Today's episode continues our mini-series on nutrition and lifestyle and the GLP-1 era. We're focusing on one of the most challenging and often misunderstood aspects of care: access. From insurance hurdles to medication shortages and interdisciplinary teamwork, we'll explore how clinicians and dieticians can collaborate to support real world success with GLP-1 therapy.
I am so excited that we have Bonnie Chambers here today. Bonnie is a family nurse practitioner specializing in metabolic health and obesity medicine. She brings a unique blend of clinical expertise and compassion to her work, helping patients navigate GLP-1 therapy safely and sustainably. Bonnie's focus on collaboration between prescribers, RDNs and other members of the healthcare team makes her a trusted voice for improving both access and patient experience. Welcome, Bonnie.
Bonnie Chambers, MSN, FNP-C: Thank you, Lisa. I’m happy to be here. Thank you for having me.
Jones: Yeah. So excited because I want to dive right in talking about the access landscape. All right, Bonnie, let's start with the big picture here. So what would you say are some of the most common access challenges that you're seeing right now for patients that are prescribed GLP-1 medications?
Chambers: Yeah, I think as far as the most common access issue, it's going to be insurance coverage for the medications. I'm seeing less and less plans covering the GLP-1s. I do not know for a fact, but I suspect that it's because of the cost. So, you have to jump through hoops a lot of the time to get the patients the medications that they need. And the rules as far as what the different insurance plans will cover the medications for, or the indications, it's all over the place. They kind of make up their own rules.
Another issue is if the GLP-1s are not covered through insurance, the high cost of out-of-pocket medications. I do not prescribe compounded medications. I advise my patients ... Well, we have a discussion regarding risk and benefit, and they understand that for me, the risk is too high when dealing with compounded medication. So I will only work with the manufacturer out-of-pocket mail order programs. For Wegovy that's NovoCare and through Zepbound, that's Eli Lilly Direct. But the cost there is very high still. You're talking hundreds of dollars. So through Novocare, Wegovy, the injection, the first two doses are now down to $199 a month. But then for the higher doses, there's three higher doses after the first two, and they're all still at about $350 a month. And then of course, there is the Wegovy pill that was recently released onto the market actually just a few weeks ago. And that cost the first two doses is at $150 a month, but then the two higher doses, you're looking at $300 for those doses. So, it's still a big chunk of change for a lot of people.
Jones: Yeah. I mean, it's a huge barrier to access when people are used to prescription costs. I don't know, $25, $10, $15. It seems high.
Chambers: It's very high. It's not feasible for a lot of patients, unfortunately. So, this is a very rewarding specialty or profession to work in, but it can also be just very frustrating seeing people not get these medications that could vastly improve their health and just being denied.
Jones: Yeah.
Chambers: Yeah.
Jones: And I'm sure it's somewhat confusing for patients that you see too, because I was mentioning commercials. I see a lot of commercials for whether it be Wegovy or Zepbound. And then of course it's like they list all the side effects and then they're like $25, but it's in an asterisk. So you might not know the answer to this, but I'm curious, how many percentage of people are actually qualified for the $25 version of it?
Chambers: Yeah. So that $25 is only if it is covered by insurance. They do have a cost savings card that patients can download programs with both the manufacturers that will bring that whatever copay it is down, sometimes to nothing. I've seen situations where, again, we'll get an approval for a patient to start Wegovy. I'm so excited, we're happy, patient's happy. And then the patient goes to pick it up from the pharmacy and they're like, oh, well, this is $1,100. Well, that's not coverage. That's not coverage. They're saying they're covering it, but they're not covering it because that, again, is not feasible or realistic. They're covering $50 of the cost or something. So again, it's all over the place and it is confusing the information that's out there and it's frustrating to see patients get their hopes up and then be let down.
Jones: Yeah. And then you're trying to contact your insurance company and figure out what's going on. So I'm sure that's not fun for patients. But that leads me into my next question about insurance coverage, the criteria for that, and then also prior authorization, and how does that shape who can actually get these medications?
Chambers: Yes. And that is always ever-changing also. So, the clinical indication from a prescriber point of view for these, for any anti-obesity medications, including the GLP-1s, is patient to have a BMI greater than 30 or a patient to have BMI between 27 and 30 with a weight-based comorbidity like hypertension, hyperlipidemia, OSA, that type of thing. But just because those are the clinical indications, it does not mean those are the indications that the insurance plans are going to agree to cover the medications for. So they will just decide that the patient has to have a BMI of 40. If they have a BMI of 35, "Oh, it's not high enough." And it's like, "Well, do they need to gain weight to get the help that they need?" It's very, very frustrating. They'll want to see a certain amount of exercise, like 150 minutes of dedicated exercise a week or that they've tried such and such other medications first and they don't put that information forward easily.
And so a lot of times you're just trying to include every single thing that they could possibly throw at you in the note to go along with the prior auth for the patient. And you're also, at the same time, having that conversation with the patient. What I like to do is make sure that they know that this is the clinical indication, but it doesn't necessarily mean that that's what your plan is going to agree upon and it's not going to be your plan's indications necessarily. But yeah, it's an interesting field for sure.
Jones: Yeah. I mean, it sounds like there's a lot that just don't cover it and they come up with reasons why not to cover it. And then we have all these patients trying to get the medication and the access isn't there.
Chambers: Exactly. As far as the different plans go, Medicare will not cover anything, any weight loss medications for patients, unless they have specifically Medicare Part D, and then it's only for the other indications that these medications are approved for, like Zepbound for apnea and Wegovy for a significant cardiovascular disease or MASH. And then it used to be that Medicaid would cover everything, but they just changed that in January. They completely dropped the GLP-1s. So I've been trying to help my patients with Medicaid figure that out and what to do next. And then with all the other, the private insurances, it all depends on what the actual, the employer has chosen with their certain plans. They're actually who chooses what's going to be covered and what's not. It's very rare that you find someone with a plan that kind of covers everything with those just simple indications, but it's a glorious thing when you do.
Jones: Well, how about, I'm curious, as I'm listening to you talk about this, are there strategies or resources that help the patients navigate when they have these access barriers more effectively? I know the one with Medicaid is new, so that you're probably navigating through that now, but what would be a strategy or resource that you might help patients go through it?
Chambers: I think we're their best resource, honestly. Unfortunately, because it's so scattered, it really is just they have to call and speak to their insurance plan, but even when they do that, they're not given the proper information. I'll have a lot of patients call their insurance and then come back to me and be like, "Well, they won't cover Zepbound or Wegovy, but they'll cover Mounjaro or Ozempic." And it's like, no, they'll cover Mounjaro or Ozempic for diabetes, but we're looking at trying to get you on something for weight loss. Then they get their hopes up again. So they're not being given the correct information when they're calling in. And I'm not saying that happens all the time, but it does happen a lot of the time.
Jones: Yeah. I mean, it's like that cyclical thing where you keep you're going back and forth and-
Chambers: There's a lot of back and forth. Yes. Yeah.
Jones: Well, thank you so much, Bonnie, for sharing your insights and experiences with us and also for helping bridge the gap between clinical management and nutrition care. And thanks to our listeners for joining another episode of Nutrition411, the podcast.
Chambers: Oh, thank you for having me.
Specific prices mentioned within this episode may have changed since the time of recording.