GLP-1 Insurance Denials, Big Pharma Prices, & What You Can Do

I’ll admit it: I’ve never paid attention to insurance companies. In the emergency department, I don’t look at a patient’s insurance status. I order the tests that are necessary and make decisions based on the care someone needs in that moment. But since opening my own practice, I’ve been forced to look at things differently.

Many of you know that I left academic medicine, became board certified in lifestyle medicine, and opened a private practice focused on health optimization. For some of my patients, weight management is part of their journey to better health. Some lose weight with lifestyle changes alone. Others are doing everything right – nutrition, exercise, sleep, stress management – and still barely budge the scale. They meet clinical criteria for an obesity diagnosis, but because they don’t have a comorbidity like diabetes, hypertension, or hyperlipidemia, their insurance denies coverage for GLP-1 medications. So, what happens next? They’re left to pay out of pocket at exorbitant prices. This makes no sense. Today’s blog is my not-so-gentle rant about what’s happening behind the scenes, why it’s happening, and what we can do about it.

The Prevention Paradox: We Wait Until You’re Sick

One of the biggest issues is that our healthcare system is built around reaction, not prevention. Longevity expert Dr. Peter Attia calls this “Medicine 2.0” – a model that waits until something breaks before we try to fix it. And it’s the exact model we follow when it comes to obesity.

We can debate all day about the causes of obesity in the United States, but the reality is that it’s multifactorial. There is no single cause to blame.  The bottom line is  that we have an obesity epidemic in the US, and it is driving up the cost of healthcare.1,2 A recent study found that a 5% reduction of BMI could save over $18 billion annually in healthcare costs.3

Yet, most insurance companies deny coverage of GLP-1 medications until patients already have diabetes, high blood pressure, or high cholesterol. In other words, insurance companies won’t treat obesity until there is damage. That’s akin to putting sunscreen on after you have sunburn.

 This isn’t medicine. It’s risk management.

GLP-1 Medications Are More Than Weight Loss

GLP-1 receptor agonists like semaglutide and tirzepatide are not vanity drugs. They’re not for people who “just want to lose a few pounds.” These medications have benefits that reach far beyond the number on a scale or pant size:

Reduced risk of type 2 diabetes: GLP-1s help lower blood sugar and can even reverse diabetes in some patients.4

Improved heart health: These medications lower inflammation, improve cholesterol, and reduce the risk of heart failure, even in patients who don’t lose significant weight.5-8

Kidney and liver protection: GLP-1s slow the progression of chronic kidney disease and improve liver function, reducing the risks associated with fatty liver disease.5,6,9,10

Better sleep and joint health: Weight loss from GLP-1 therapy can ease joint pain and reduce sleep apnea, improving overall quality of life.11-13

Potential cognitive benefits: Early research suggests these drugs may lower the risk of Alzheimer’s and improve cognitive function.14-16

Yet, patients who stand to benefit the most can’t get access unless they’re already sick.

Pharmaceutical Companies Are Not Off The Hook

With all the data on healthcare cost savings, Medicare conducted a cost analysis of the savings versus the cost of covering the costs of GLP-1s. They concluded it costs more money to cover the medications at their current prices than to pay for the associated healthcare costs of obesity. This was independently verified by another study published in JAMA.17 The costs of these medications can be resolved directly by the pharmaceutical companies.

Pharmaceutical companies spend an average of $1.1-$1.4 billion dollars on research and development of new drugs.18-20 Only 10-15% of the drugs under development reach the market.18,20,21 We are told that companies factor the cost of these failures into their drug prices, which drives up the price tag, but do not be fooled. Pharmaceutical companies remain among the most profitable businesses in the U.S. economy. A 2024 report found that drug manufacturers average a net income margin of 23%, more than double the S&P 500 average.22  

GLP-1s in particular are a cash cow. Novo Nordisk and Eli Lilly, makers of semaglutide and tirzepatide, have seen billions in revenue since launching these drugs. In 2024, Eli Lilly reported nearly $11.54 billion in sales from Mounjaro and $4.9 billion from Zepbound. That number is expected to grow as Zepbound prescriptions increase.23 Meanwhile, the cost to manufacture a single dose of these medications is estimated to be under $5.24 List prices exceed $1,000 per month in the U.S.!

And if that isn’t frustrating enough, many pharmaceutical companies offer discount programs if you pay cash directly through them, bypassing insurance and retail pharmacies entirely. This tells us two things:

  1. They can afford to offer these drugs at a lower price.
  2. The retail markup and insurance middlemen aren’t the only part of the problem. The manufacturers are aggressively protecting their margins.

This is not about recovering the cost of research. This is not about innovation. This is about profit, pure and simple.

A Call to Action

You may think there is no way to control what insurance company deny. This is false. State and federal governments can pass legislation to control these factors.

State lawmakers regularly pass insurance mandates that require private health insurers in their state to cover certain benefits, treatments, or drugs. These laws are then enforced by the state’s insurance regulator or commissioner.25 In fact, it has already happened with fertility treatment,26,27 mental health and substance use treatment,28,29 and reconstructive surgery.30-32 The same can be done with GLP-1 medications for obesity without comorbidities.

With regard to pharmaceutical costs, there are indirect ways of bringing the price down by capping Medicare and Medicaid reimbursements.33 The 2022 Inflation Reduction Act now allows Medicare to negotiate lower prices with drug companies for some medicine with high Medicare spending.34 The largest implementation will be in 2026, but semaglutide and terzepatide are not included on that list.  

So what does this mean for you? Write your legislators Call their offices. Show up in person. We need legislative will to change the rules and that only happens when doctors and patients speak up together. Insurance companies should not dictate treatment decisions. Pharmaceutical companies should not bankrupt people for trying to get healthy. Rant over.

References

  1. Ng M, Dai X, Cogen RM, et al. National-level and state-level prevalence of overweight and obesity among children, adolescents, and adults in the USA, 1990–2021, and forecasts up to 2050. The lancet. 2024;404(10469):2278-2298.
  2. Cawley J, Biener A, Meyerhoefer C, et al. Direct medical costs of obesity in the United States and the most populous states. Journal of managed care & specialty pharmacy. 2021;27(3):354-366.
  3. Thorpe KE, Joski PJ. Estimated reduction in health care spending associated with weight loss in adults. JAMA Network Open. 2024;7(12):e2449200-e2449200.
  4. American Diabetes Association Professional Practice Committee. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in diabetes–2025. Diabetes Care. 2025;48(Supplement_1):S167-S180.
  5. Lee MMY, Sattar N, Pop-Busui R, et al. Cardiovascular and Kidney Outcomes and Mortality With Long-Acting Injectable and Oral Glucagon-Like Peptide 1 Receptor Agonists in Individuals With Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Trials. Diabetes Care. 2025;48(5):846-859. doi:10.2337/dc25-0241
  6. Madsbad S, Holst JJ. Cardiovascular Effects of Incretins: Focus on Glucagon-Like Peptide-1 Receptor Agonists. Cardiovascular Research. 2023;119(4):886-904. doi:10.1093/cvr/cvac112
  7. Ussher JR, Drucker DJ. Glucagon-Like Peptide 1 Receptor Agonists: Cardiovascular Benefits and Mechanisms of Action. Nature Reviews Cardiology. 2023;20(7):463-474. doi:10.1038/s41569-023-00849-3
  8. Nauck MA, Meier JJ, Cavender MA, et al. Cardiovascular Actions and Clinical Outcomes With Glucagon-Like Peptide-1 Receptor Agonists and Dipeptidyl Peptidase-4 Inhibitors. Circulation. 2017;136(9):849-870. doi:10.1161/CIRCULATIONAHA.117.028136
  9. Yabut JM, Drucker DJ. Glucagon-Like Peptide-1 Receptor-Based Therapeutics for Metabolic Liver Disease. Endocrine Reviews. 2023;44(1):14-32. doi:10.1210/endrev/bnac018
  10. Wang Y, Zhou Y, Wang Z, et al. Efficacy of GLP-1-based Therapies on Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis: A Systematic Review and Meta-Analysis. The Journal of Clinical Endocrinology and Metabolism. 2025;doi:10.1210/clinem/dgaf336
  11. Drucker DJ. GLP-1-based Therapies for Diabetes, Obesity and Beyond. Nature Reviews Drug Discovery. 2025;doi:10.1038/s41573-025-01183-8
  12. Wu JY, Chen CC, Tu WL, et al. Clinical Impact of Tirzepatide on Patients With Obstructive Sleep Apnea and Obesity. Chest. 2025;doi:10.1016/j.chest.2025.03.030
  13. Yang R, Zhang L, Guo J, et al. Glucagon-Like Peptide-1 Receptor Agonists for Obstructive Sleep Apnea in Patients With Obesity and Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis. Journal of Translational Medicine. 2025;23(1):389. doi:10.1186/s12967-025-06302-y
  14. Tang H, Donahoo WT, DeKosky ST, et al. GLP-1RA and SGLT2i Medications for Type 2 Diabetes and Alzheimer Disease and Related Dementias. JAMA Neurology. 2025;82(5):439-449. doi:10.1001/jamaneurol.2025.0353
  15. Au HCT, Lam PH, Lim PK, McIntyre RS. Role of Glucagon-Like Peptide-1 on Amyloid, Tau, and Α-Synuclein: Target Engagement and Rationale for the Development in Neurodegenerative Disorders. Neuroscience and Biobehavioral Reviews. 2025;173:106159. doi:10.1016/j.neubiorev.2025.106159
  16. Sundararaman L, Gouda D, Kumar A, et al. Glucagon-Like Peptide-1 Receptor Agonists: Exciting Avenues Beyond Weight Loss. Journal of Clinical Medicine. 2025;14(6):1978. doi:10.3390/jcm14061978
  17. Hwang JH, Laiteerapong N, Huang ES, Mozaffarian D, Fendrick AM, Kim DD. Fiscal Impact of Expanded Medicare Coverage for GLP-1 Receptor Agonists to Treat Obesity. American Medical Association; 2025:e250905-e250905.
  18. Mulcahy A, Rennane S, Schwam D, et al. Use of Clinical Trial Characteristics to Estimate Costs of New Drug Development. JAMA Network Open. 2025;8(1):e2453275. doi:10.1001/jamanetworkopen.2024.53275
  19. Sertkaya A, Beleche T, Jessup A, Sommers BD. Costs of Drug Development and Research and Development Intensity in the US, 2000-2018. JAMA Network Open. 2024;7(6):e2415445. doi:10.1001/jamanetworkopen.2024.15445
  20. Wouters OJ, McKee M, Luyten J. Estimated Research and Development Investment Needed to Bring a New Medicine to Market, 2009-2018. JAMA. 2020;323(9):844-853. doi:10.1001/jama.2020.1166
  21. Schuhmacher A, Hinder M, Brief E, Gassmann O, Hartl D. Benchmarking R&D Success Rates of Leading Pharmaceutical Companies: An Empirical Analysis of FDA Approvals (2006-2022). Drug Discovery Today. 2025;30(2):104291. doi:10.1016/j.drudis.2025.104291
  22. Campaign for Sustainable Rx P. Margin Analysis: Pharmaceutical Manufacturers’ Average Annual Net Income Margin. 2024. 2024/11/18. https://www.csrxp.org/wp-content/uploads/2024/11/CSRxP-Margin-Analysis-One-Pager-11.18.24.pdf
  23. Murphy T. Diabetes and obesity drugs fuel Eli Lilly profit in the final quarter of 2024. AP News. 2025/02/06. https://apnews.com/article/eli-lilly-fourth-quarter-mounjaro-zepbound-ca026922525a9e3abb1b75d329628bef
  24. Barber MJ, Gotham D, Bygrave H, Cepuch C. Estimated sustainable cost-based prices for diabetes medicines. JAMA Network Open. 2024;7(3):e243474-e243474.
  25. Bolin JN, Buchanan RJ, Smith SR. State regulation of private health insurance: Prescription drug benefits, experimental treatments, and consumer protection. The American journal of managed care. 2002;8(11):977-985.
  26. Kawwass JF, Penzias AS, Adashi EY. Fertility—a human right worthy of mandated insurance coverage: the evolution, limitations, and future of access to care. Fertility and Sterility. 2021;115(1):29-42.
  27. Peipert BJ, Montoya MN, Bedrick BS, Seifer DB, Jain T. Impact of in vitro fertilization state mandates for third party insurance coverage in the United States: a review and critical assessment. Reproductive Biology and Endocrinology. 2022;20(1):111.
  28. Hodgkin D, Horgan CM, Stewart MT, et al. Federal parity and access to behavioral health care in private health plans. Psychiatric Services. 2018;69(4):396-402.
  29. Harwood JM, Azocar F, Thalmayer A, et al. The Mental Health Parity and Addiction Equity Act evaluation study: impact on specialty behavioral health care utilization and spending among carve-in enrollees. Medical care. 2017;55(2):164-172.
  30. American Academy of Dermatology A. PS‑Definitions of Cosmetic & Reconstructive Surgery. 2024. 2024. https://server.aad.org/forms/policies/Uploads/PS/PS-Definitions%20of%20Cosmetic%20&%20Reconstructive%20Surgery.pdf
  31. American Academy of Dermatology A. PS‑Restorative and Reconstructive Interventions for Vascular Anomalies and Malformations. 2024. 2024. https://server.aad.org/forms/policies/Uploads/PS/PS-Restorative%20and%20Reconstructive%20Interventions%20for%20Vascular%20Anomalies%20and%20Malformations.pdf
  32. Klein M, Ha M, Yang A, Ngaage LM, Slezak S, Rasko Y. A national review of insurance coverage of noncancerous breast reconstruction. Annals of plastic surgery. 2021;87(3):232-237.
  33. Kesselheim AS, Avorn J, Sarpatwari A. The high cost of prescription drugs in the United States: origins and prospects for reform. Jama. 2016;316(8):858-871.
  34. Vogel M, Kakani P, Chandra A, Conti RM. Medicare price negotiation and pharmaceutical innovation following the Inflation Reduction Act. Nature Biotechnology. 2024;42(3):406-412.

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