How Drug Companies Are Crafting Clever Tactics to Get Insurers to Cover High-Cost Meds like Zepbound

Pharmaceutical giant Eli Lilly is playing an intriguing hand in its quest to persuade insurers to cover their popular weight loss medications. The company is betting on the broader utility of its drugs by sponsoring studies that explore their effectiveness in treating conditions beyond obesity and type 2 diabetes. This strategic move comes as insurers have been hesitant to cover these medications, leaving many patients to shoulder the financial burden themselves. Eli Lilly is now aiming to demonstrate that their drugs can also mitigate sleep apnea, a common and potentially serious sleep disorder.

Eli Lilly, the manufacturer behind the weight loss and type 2 diabetes drugs Zepbound and Mounjaro, has already conducted two promising studies. These studies, which included a combined total of 470 participants, revealed that over 60 percent of those taking Zepbound experienced a significant reduction in the severity of their sleep apnea symptoms compared to those who received a placebo. The results were compelling enough that Lilly has included them in their application to the Food and Drug Administration (FDA), seeking to officially add sleep apnea to the list of conditions that Zepbound can treat. Derek Asay, Lilly’s senior vice president of government strategy and federal accounts, believes that this builds a robust “wall of evidence” and provides a solid rationale for insurers to reconsider their stance.

Glucagon-like peptide-1 (GLP-1) agonists, the class of drugs that includes Zepbound, are not only gaining attention for their weight-loss capabilities but also for their potential to treat a range of other conditions. Drugs like Zepbound, and Novo Nordisk’s Ozempic and Wegovy, work by mimicking the gut’s sense of fullness, thus reducing appetite. However, emerging evidence suggests that these drugs may also alleviate symptoms of alcoholism, dementia, arthritis, and Parkinson’s disease. Pharmaceutical companies are keenly aware of these off-label uses and are hoping to secure broader insurance coverage once the drugs receive regulatory approval for treating conditions beyond just weight loss and diabetes.

In March, the FDA approved Novo Nordisk’s Wegovy as a treatment for reducing the risk of heart disease and stroke, marking a significant milestone. This approval was a cause for celebration among many healthcare professionals who see these drugs as transformative. Cedars-Sinai cardiologist Martha Gulati has expressed hope that insurers will come to understand the broader benefits of these medications, viewing them as more than just “vanity drugs.”

Despite the excitement and the potential for broader applications, there remains a cloud of uncertainty. The medical community is still grappling with the fundamental question of how GLP-1s work. Are the additional benefits merely a byproduct of weight loss, or is there another underlying mechanism at play? This enigma is fueling ongoing research and debate within the medical field. As it stands, the exact mechanisms by which these drugs exert their multifaceted effects remain largely unknown, but the pursuit to uncover these secrets continues with fervor.

Eli Lilly’s latest gambit is a calculated move that could reshape how insurers view weight loss medications. By expanding the recognized benefits of drugs like Zepbound, the company hopes to not only improve patient outcomes but also ease the financial burden on those who need these treatments the most. Whether this strategy will pay off remains to be seen, but one thing is clear: the stakes are high, and the potential rewards could be life-changing for many.