Sarah Kalemkerian can name every diet she’s been on since she started trying out weight-loss fads with her dad in the 1980s.
“There was the Scarsdale diet, I’ve done South Beach, I’ve done Atkins,” recalls Kalemkerian, a school administrator with the city Department of Education. “I’ve been a member of Weight Watchers probably no fewer than 20 times in my life.”
Kalemkerian, now 50, said she finally had a breakthrough after she found out her health insurance through the city covers Zepbound, part of a class of drugs known as GLP-1s that have increasingly become go-to solutions for weight loss. She started the medication in January and has shed about 30 pounds along with her persistent food cravings.
“It changed my life,” she said.
But now that progress is at risk. Kalemkerian recently found out from EmblemHealth, which administers her city health benefits, that she will lose coverage for Zepbound next year — and she said she can’t afford the high-priced injectable on her own. Without a discount, Zepbound can cost over $1,000 for a one-month supply for those without insurance. Kalemkerian currently pays just a $25 copay every three months.
Kalemkerian is one of nearly 1,000 city workers and their dependents who started on weight-loss drugs like Zepbound or Wegovy after they were added to a list of medications covered under an optional prescription rider for one of the city’s health plans earlier this year, according to EmblemHealth.
But Liz Garcia, a spokesperson for the city, said the drugs were added in error, and keeping them on the list of covered medications could drastically increase health care premiums for employees.
“The city never planned to cover these drugs due to the steep costs that would fall on city employees,” Garcia said.
She added that the city will continue covering GLP-1 drugs for patients who use them to treat diabetes, but not weight loss.
The change in coverage comes at a time when interest in expensive GLP-1 drugs for weight loss is skyrocketing, and employers, Medicare, and other insurance providers are grappling with how to respond.
Medicare, the federal insurance program for older adults, has long been banned from covering weight-loss drugs. But there’s a growing body of evidence that GLP-1 drugs can also be effective for treating or preventing some medical conditions associated with obesity. For instance, the U.S. Food and Drug Administration recently approved Wegovy to reduce the risk of heart attacks, strokes and cardiovascular death in people who are overweight or obese, and Medicare drug plans can now cover Wegovy if it’s prescribed for that purpose.
Preventing serious medical conditions associated with obesity could theoretically also save employers money on health costs in the long term.
But employers that cover GLP-1 drugs for weight loss generally do so as a special perk to attract top talent, not for the potential long-term savings — which they may never see, said Adam Okun, the employee benefits practice leader for the northeast region at Epic, a national insurance brokerage and consulting firm.
And only some employers are willing to take on the up-front costs.
“White-collar employers, such as financial services, accounting firms, law firms and private equity, are overwhelmingly covering the weight-loss drugs,” Okun said. But, he added, the benefit is less common at firms with more hourly employees, such as those in retail or logistics.
Covering these drugs can increase an employer’s overall health care costs by about 3%-5%, Okun said. He added that some companies seek to put up barriers to employees using the medications, such as imposing requirements that they also have to participate in lifestyle programs designed to encourage healthy habits and track their weight.
Kalemkerian and other city employees on Zepbound who spoke with Gothamist said EmblemHealth began requiring them to participate in one such program, called WellSpark, earlier this year in order to renew their prescriptions.
Some employers eventually decide to reverse course and stop coverage altogether once they see the price tag, Okun said.
What happens when the insurance coverage runs out?
When patients stop taking GLP-1s, either because of a loss of insurance coverage or for other reasons, they often gain back the weight they lost and can experience other side effects such as depression, said Dr. Jennifer Ng, a primary care doctor at Mount Sinai.
“Something I counsel patients on because I think it’s not as well understood by the public is that it is meant to be long-term use,” said Ng, who specializes in treating obesity.
She added that she frequently talks to patients about the cost of these drugs, since insurance coverage varies widely. Some patients who can’t afford name-brand GLP-1s have opted for so-called “compounded” alternatives, which are typically cheaper.
Pharmacies and clinics are allowed to mix ingredients to make their own compounded version of an FDA-approved drug if the FDA declares that there’s a commercial shortage. That rule has been applied in recent years to popular GLP-1 weight-loss medications, although it’s unclear how long the approvals will last.
Ng said she advises patients to avoid compounded drugs because of safety concerns. Compounded drugs are not individually reviewed and approved by the FDA, and the agency has cautioned that some patients have had bad reactions to compounded GLP-1s because of incorrect dosing. Some patients even had to be hospitalized.
Still, Michael Ragusa, a city employee with Correctional Health Services, said he would consider a compounded version of Zepbound if it’s available when he loses his insurance coverage for the drug next year.
“Once you get on this medication, you don’t want to stop because the results are so good,” Ragusa said.
The city will discontinue its coverage for Zepbound and Wegovy for weight loss in January, according to a letter EmblemHealth sent to those affected earlier this month. The letter added that those who are already approved for these drugs will be allowed to stay on them through June 2025, or the date their current authorization expires — whichever comes first.
This article was updated with additional information on pricing and discounts for Zepbound.
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