Wegovy, Mounjaro: Suffolk County issues new guidelines for access to costly weight loss drugs

Suffolk County employees and beneficiaries hoping to shed pounds using the latest weight loss medications will face stricter requirements to prove they need the pricey drugs in order to get them covered by insurance, officials said.

Starting Jan. 1, the Employee Medical Health Plan of Suffolk County will require monitoring, counseling, a higher body mass index and, in some cases, health conditions that put someone at higher risk for serious illness, according to an all-employee memo sent by the county executive's office. 

The guidelines are part of a national trend by municipal governments and private firms struggling to manage ballooning costs of popular drugs such as Wegovy and Mounjaro. Some states and companies have decided to drop coverage of these medications rather than deal with the growing price tags, experts said.

For example, Suffolk County's costs for these medications, known as GLP-1 drugs, increased more than $3 million over two years, from $1.2 million in the second quarter of 2022 to $4.3 million in the second quarter of 2024, according to officials.

Employers choosing to continue coverage of these medications are turning to third-party companies to help manage costs and set limits on who should have access to them, said Matthew Rae, an analyst at KFF, a health policy research and news organization.

"There are very few employers who are covering this the same way you cover low-cost drugs," said Rae. "This is a hugely expensive drug. Employers are thinking about how they want to do this."

Without insurance, one month of Ozempic can cost about $936; Wegovy, $1,349 and Mounjaro $1,023 in the U.S., according to a KFF analysis.

Currently about 2,100 Suffolk County employees not on Medicare have active prescriptions for GLP-1 medications, according to a county spokesman Mike Martino.

Insurance holders and their beneficiaries will need to prove they have a Body Mass Index of 32 or higher, which is considered the lower levels of obesity by the Centers for Disease Control and Prevention. The previous threshold was 28, which is in the overweight range.

If the individual has multiple health conditions, such as high blood pressure or cholesterol and a BMI of 27 or above, they will also be covered. Those on the medications, known as GLP-1s or glucagon-like peptide-1, will additionally weigh in four times a month on "smart scales" using an app, and have virtual meetings with health coaches and get nutrition tips.

The new guidelines ensure those at risk of serious health issues due to obesity, and those who are overweight with conditions such as high blood pressure, will still have access to the medication, said Louis Civello, president of the Suffolk County Organization of Public Employees and the Suffolk County PBA, who helped negotiate the latest health benefits.

Civello said taking these medications, in general, should be a short-term solution to help people lose weight and prioritize a healthy lifestyle, which includes learning the importance of proper nutrition and exercise.

"We put guardrails in place, which still allows the drug in cases where we think they'll be beneficial, but it's not a one-shot-fits-all," said Civello. "It's not something that we want to see members on for the rest of their lives."

"Heading off long-term chronic disease now will save money in the long run," he said. "So these drugs were important and there is a great number of people in the plan using these drugs."

On Tuesday the Biden administration proposed having Medicare and Medicaid cover the medications. Currently, Medicare does not cover weight loss drugs and Medicaid coverage is decided by individual states. The rule change, which could cost as much as $35 billion over the next decade, according to the Associated Press, will need to be approved by President-elect Donald Trump's administration.

New requirements

Members of Suffolk's Employee Medical Health Plan eligible for the medication will be required to download, a weight-loss app operated by Omada Health, to help them manage the weight-loss medications.

Coaches and peer groups will also provide tips on exercise and better nutrition, according to the company's website. Members will also receive the scale that will allow them and their coaches to track their weight.

Under the current guidelines, members didn't have to show proof of their BMI, Civello said.

"We'd have to take the doctor's word that the BMI is what you say it is," he said.

People who are taking the medication but don’t meet the new BMI requirements will no longer have their medications covered. They will be redirected to support groups, nutritionists and other resources, Civello said.

In a statement, the Suffolk Association of Municipal Employees President Daniel Levler said it is urging its members to "maintain their eligibility to receive these medications by participating in the required weight management programs."

Nassau County officials did not respond to requests for comment on whether its current plan covers weight loss drugs. Earlier this month, the union that represents county employees sued the government about changes to its health plans.

KFF analyst Rae said many medications also require lifestyle changes to be more effective. But not everyone will be open to those requirements.

"It's an additional challenge on people," he said, referring to the required weigh-ins and health coach check-ins. "It’s also making sure that the people who are doing it are really committed."

Most of these medications were originally formulated to treat people with diabetes. GLP-1s lower blood sugar levels, protect the heart and kidneys and can promote weight loss, according to the CDC.

But their weight loss properties grabbed the attention of the public and people without diabetes started seeking these drugs.

In 2021, the U.S. Food and Drug Administration approved Wegovy for "chronic weight management." That made it available to people with a body mass index of 30 or greater, who are considered obese. People who had a BMI of 27, which is overweight, or higher could also get prescriptions if they also had another condition such as high blood pressure or high cholesterol.

Rae said "tens of millions of people" across the U.S. fall into those categories.

Managing demand

"Every employer is managing demand," he said.

Rae said options range from raising the BMI to a higher number, such as 35, which would make the eligible pool smaller, or not covering it all for weight loss, which many employers have decided to do.

According to the KFF 2024 Employer Health Benefits Survey, only 25% of companies with 1,000 or more employees cover these medications for weight loss. More than 50% of companies with 200 or more employees have "some type of condition or requirement associated with covering these medications," according to the survey.

Earlier this year, the state of Connecticut signed a contract with a weight management program for employees who want to use the medications. The state's comptroller said the projected cost for the drugs was an "unsustainable" 50% year-over-year increase, according to a statement on his website.

Both North Carolina and West Virginia dropped coverage for their employees earlier this year, citing skyrocketing costs.

Members of the North Carolina State Health Plan board of trustees said the cost of these medications for weight loss was "projected to exceed $170 million in 2024, jumping to more than $1 billion over the next six years ... more than the state Health Plan spends on cancer, rheumatoid arthritis, and chemotherapy medications."

By Lisa L. Colangelo

lisa.colangelo@newsday.com@lisalcolangelo

Lisa joined Newsday as a staff writer in 2019. She previously worked at amNewYork, the New York Daily News and the Asbury Park Press covering politics, government and general assignment.