New Yorkers considering taking weight-loss drugs like Wegovy and Ozempic must navigate complex rules for public and private health insurance plans.
At the same time, state lawmakers are debating measures aimed at removing barriers to the medications, which have received national attention as demand skyrockets and concerns mount about the drugs’ costs to consumers and taxpayer-supported health plans such as Medicare.
The stakes are clear in New York, where about 4.4 million adults, or 30%, have obesity. In some counties, that adult obesity rate approaches nearly 50%, with some rural and poor communities across upstate hit hardest by the obesity epidemic, state data show.
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What to know NY weight-loss drug legislation
State lawmakers have proposed several bills seeking to improve access to weight-loss drugs, including one that would seek to lift the Medicaid ban on coverage of the medications to aid the poor and low-income New Yorkers with the highest obesity rates.
That bill, which failed to move beyond committee debate this year, would require Medicaid to cover “prescription drugs approved by the federal Food and Drug Administration for chronic weight management in adults with obesity with at least one weight-related condition,” state records show.
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Another measure aims to require comprehensive health insurance coverage for treatment of obesity, “including coverage for prevention and wellness, nutrition counseling, intensive behavioral therapy, bariatric surgery and FDA-approved anti-obesity medication.
That bill, which maintains health insurers’ ability to determine the medical necessity of the prescription, also remained in early committee debates.
How a New York health plan denied a Wegovy prescription
Meanwhile, state regulators and health plans have ongoing discussions about which patients should be approved for weight-loss prescription drugs.
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One case in 2023 involved the state Department of Financial Services upholding the Excellus health plan’s denial of a Wegovy prescription written for a unidentified woman in her 50s. She met the body mass index requirement of greater than 30 to take the drug, but the health plan denied the prescription, in part, because she stopped participating in Weight Watchers, state records show.
The health plan “requires participation in a weight management program at the time Wegovy is approved, with evidence of active participation for at least the prior three months and continuing during treatment,” regulators wrote in upholding the denial. They noted the health plan asserted the drug “is best used as an adjunct to a diet and exercise program.”
The woman noted she was using Weight Watchers for eight months before stopping, adding she regularly visited with a doctor as part of treatment for high blood pressure. Her body mass index was 37 at the time of the denial, approaching the crucial level of 40 — when it is considered a high-risk chronic obesity condition responsible for myriad serious illnesses such as heart disease and certain cancers, state and federal records show.
National debate over Wegovy, weight-loss drugs
As the list of medical uses for these drugs grows, more people are asking their doctors for a prescription for meds that can cost more than $10,000 per year. Meanwhile, employers and health insurance plans are attempting to slow spending on these drugs.
North Carolina’s health insurance program for state employees earlier this year discontinued coverage for select prescription weight-loss medications, citing the high costs.
What are obesity, diabetes rates in New York?
Meanwhile, about 1.7 million adult New Yorkers have diabetes — which is a top condition being treated by Ozempic, state data show. And the condition is disproportionately affecting more Black adults (nearly 15%) than white (9%) and Hispanic (11%).
In Monroe County, about 10% of adults have diabetes, slightly below the state average of 11.4%. Orleans County had the highest adult diabetes rate in the state at nearly 17%. Monroe’s adult obesity rate is about 31%, while Orleans rate is 48%.
By contrast, Westchester and Rockland counties had adult diabetes rates of about 10%, with adult obesity rates of 24% and 25%, respectively.
— Ken Alltucker of USA TODAY contributed reporting
— David Robinson is the New York State Team health care reporter for the USA TODAY Network. His more than 15-year investigative reporting career has included awards for coverage of the opioid epidemic, hospital and nursing home abuses, health inequality, COVID-19 and emergency response failures.
This article originally appeared on Rockland/Westchester Journal News: Have you tried to take Wegovy, Ozempic in New York? Tell us your story
