http://www.nytimes.com/2024/02/02/health/ozempic-wegovy-weight-loss-pharmacies.html

Six Reasons Why It’s So Hard to Get Your Weight-Loss Drugs

An array of obstacles makes it difficult for patients to obtain Wegovy or Zepbound. Finding Wegovy is “like winning the lottery,” one nurse practitioner said.

By Reed Abelson and Rebecca Robbins

The reporters interviewed patients, obesity medicine specialists, pharmacists, employers, insurance executives and industry analysts.

Feb. 2, 2024

Talk to people who have tried to get one of the wildly popular weight-loss drugs, like Wegovy, and they’ll probably have a story about the hoops they had to jump through to get their medication — if they could get it at all.

Emily Weaver, a nurse practitioner in Cary, N.C., said she told her patients that finding Wegovy was “like winning the lottery.”

Here are six reasons why.

1. Demand is very high.

Fueled in part by TikTok videos and celebrity testimonials, people are increasingly seeking prescriptions for appetite-suppressing medications. The drugs in this class have long been used to treat diabetes but more recently have been recognized for their extraordinary ability to help patients lose weight. The medications are injected weekly and have sticker prices as high as $16,000 a year.

About 3.8 million people in the United States — four times the number two years ago — are now taking the most popular weight-loss drugs, according to the IQVIA Institute for Human Data Science, an industry data provider.

Some of these prescriptions are for diabetes. The medicines are Novo Nordisk’s Ozempic and Wegovy (the same drug sold under different brand names), and Eli Lilly’s Mounjaro and Zepbound (also the same drug).

Pent-up demand is even higher, because many people who want the drugs cannot find or afford them. Without insurance coverage, people have to pay out of their own pockets. If they obtain a coupon offering a discount from Eli Lilly, people with commercial insurance pay $550 a month for Zepbound. For those who are commercially insured, a coupon from Novo Nordisk for Wegovy reduces the pharmacy bill by $500, making the cost roughly $1,000 a month.

The Business of Weight Loss Drugs

•  What the Drugs Really Cost: Drug companies are making billions from a new class of in-demand weight-loss treatments. But the prices are not what they seem.
• Barriers to Access: Talk to people who have tried to get one of the new weight-loss drugs and they’ll probably have a story about the hoops they had to jump through to get their medication. Here are six reasons why getting the medications is so difficult.
•  Reshaping Denmark’s Economy: Novo Nordisk, the Danish company behind Ozempic and Wegovy, two popular obesity medications, is now responsible for most of the country’s economic growth.
•  Wegovy Shortage: With demand climbing faster than supply can keep up, a shortage of the medication is fueling frustration among potential patients and people seeking to refill their prescriptions.

And the interest is expected to keep growing.

2. The supply is limited.

Novo Nordisk and Eli Lilly have tried to respond by ramping up production, but they have not been able to churn out enough to come close to meeting demand.

Only a limited number of plants in the world are ready and available to make the injectable drugs, which are harder to manufacture than pills. Adding to the complexity, each company is manufacturing at least five dosage strengths of its drug.

“These are complicated sites, really technically demanding work, very capital intensive, populated with machines that are highly specialized and often made in not-so-big companies,” Eli Lilly’s chief executive, David Ricks, said last month.

For Eli Lilly, which sells Zepbound for weight loss, a crucial bottleneck has been making enough of the pens that are used to inject the drug.

Novo Nordisk, the manufacturer of Wegovy, has struggled even more than Eli Lilly to make enough of its drug, though it is trying to catch up. It said that in January it more than doubled the supply of doses for new patients, estimating the medication would reach pharmacies within a couple of weeks.

This situation is unusual, said Erin Fox, an expert at the University of Utah who tracks drug shortages. Most scarcities involve older medications in which there is little financial incentive to manufacture the drugs. “Usually if there is a very profitable drug, we don’t see shortages,” she said.

3. Insurance often won’t pay, and the drugs are too expensive for most people.

At this time, many employers and health plans do not cover obesity drugs. Medicare, the federal program that covers people 65 and older and disabled adults, is prohibited by law from covering medications for the treatment of obesity. Few people under Medicaid, the state-federal program for the poor, have coverage.

Mercer, a company that advises employers on their health benefits, said that about 60 percent of the large employers it surveyed last year did not currently cover obesity drugs. “These medications in the past have historically been considered more of a lifestyle type of medication,” rather than an essential treatment for a condition like diabetes or cancer, said Alysha Fluno, a consultant at Mercer.

4. Pharmacies often don’t keep the drugs in stock.

Patients who were prescribed Wegovy or Zepbound frequently report calling a long list of pharmacies only to find that none of them have the medication. Both the big drugstore chains and independent pharmacies often don’t keep the weight-loss drugs stocked, though many will order them at a patient’s request.

Pharmacists say they cannot afford to tie up tens of thousands of dollars in weight-loss drug inventory when they need the money for more pressing needs, like paying their work force.

“You may not be able to make payroll because your refrigerator is full of Wegovy,” said Douglas Hoey, chief executive of the National Community Pharmacists Association, the trade group for independent pharmacists.

5. Some pharmacies say they can’t make money from the drugs.

Pharmacies buy a drug from a wholesaler and dispense it to people. They are then paid for doing so by a pharmacy benefit manager, the intermediary working for a person’s health insurer or employer. The three largest are CVS Caremark, Express Scripts and Optum Rx.

But the pharmacy benefit managers, or P.B.M.s, typically pay such low rates that independent pharmacists say they usually lose money on weight-loss drugs. The economics are so bad that some pharmacies are declining to fill their patients’ Wegovy and Zepbound prescriptions.

In a survey conducted last fall by the independent pharmacists’ trade group, 153 pharmacists said they had to turn a patient away because they were losing money on a weight-loss drug. When they were paid below cost for those medicines, they lost $38 on average filling a one-month prescription, respondents said.

“The fact that pharmacies are being asked to lose money on these really expensive drugs has put them in a really difficult position with patients,” Mr. Hoey said.

Katie Payne, a spokeswoman for the Pharmaceutical Care Management Association, the trade group for P.B.M.s, said that blaming them for supply shortages at the pharmacy “overlooks the role P.B.M.s play in trying to get insurers and employers the best price possible.” She added that “the price set by weight-loss drug manufacturers is the fundamental problem.”

6. When insurance does pay for the drugs, they can still be hard to get.

More employers and health plans have begun covering the medications for weight loss, persuaded by research suggesting the drugs can avert expensive health problems like heart attacks and strokes. But the high demand for the drugs has prompted most plans to impose restrictions on use.

The vast majority of plans require a doctor to prove the patient meets the criteria for the medication, a cumbersome process that can involve a lot of paperwork and delays. Some plans require patients to enroll in an educational or coaching program about nutrition and exercise for six months before the drug can be covered by insurance. Tricare, the health insurance program for service members, requires patients to try other, cheaper and less-effective drugs before it will pay for Wegovy or Zepbound.

But the market is in flux as costs to employers or plans keep rising. A few plans, including the one for North Carolina state employees, have recently dropped coverage because of the high cost of these drugs.

Shawn Gremminger, president of the National Alliance of Healthcare Purchaser Coalitions, a group that represents employers, said, “At some point in the next couple of years, a new standard of care will be developed,” leading to more coverage of the drugs.