This could be a game-changer for obesity treatment

DianaCox

Bad Cop
Tirzepatide was just approved for T2D, and it induced about 20% weight loss as well. This study is part of what’s going to be submitted to the FDA to get it approved as a drug for weight loss.

It is expensive and will probably NOT be covered by most insurance for weight loss. It’s a once/week injection.
 

Attachments

DianaCox

Bad Cop

“That class of drugs is called incretins. Initially created to spur insulin production in diabetic patients, incretins often left participants in drug trials with two notable side effects: satiety and delayed gastric emptying. In other words, recipients feel full quicker, while food itself moves from stomach to intestine more slowly, which makes you feel even more full. The combination of those effects caused patients to eat less and consistently lose weight.”

I wonder if I can be prescribed this drug and have it covered by Medicare because it might help with my chronic middle-of-the-night barfing when my stomach is completely empty?
 

DianaCox

Bad Cop
Similar but not the same.

“Tirzepatide is a dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist (RA) that was recently approved by the FDA for the treatment of type 2 diabetes. The drug is manufactured by Eli Lilly & Co. under the brand name Mounjaro™ and was approved in May 2022.

Semaglutide, on the other hand, is a glucagon-like peptide-1 receptor agonist, or GLP-1, drug that’s available under multiple brand names including Ozempic®, Wegovy®, and Rybelsus®. All three of these are made by Danish pharmaceutical company Novo Nordisk. Ozempic® and Rybelsus® are indicated for type 2 diabetes, whereas Wegovy® is specifically indicated for the treatment of overweight and obesity.”

(This website is an online weight loss clinic - I do not in any way endorse it!)

 

DianaCox

Bad Cop
Very hard to say, because it depends on your insurance and income, and likely your diagnosis, as well as how cooperative/creative your doctor is with coding.
  • There is a $25 copay plan, but you have to have regular (not Medicare/Medicaid) insurance and meet financial requirements
  • Some insurance covers it, at least for diabetes, but of course copays will vary
  • Most insurance companies adamantly do NOT cover weight loss drugs
  • I’m not sure how Medicare Part D plans will handle it, including what requirements they will require (do you have to have diabetes? do you have to have tried cheaper meds and failed?) and what the copays will be at each step of the pre-deductible, after deductible, donut hole, and catastrophic levels.
  • Also, starting in 2025, max copay for Medicare will be $2000, so that could make it good for anyone who can afford whatever the premiums will be.
  • However, yesterday I was talking to the guy who helps us figure out which Part D plan to pick for next year, and he told me Medicare now has a vastly improved website for doing it yourself, but he walked me through it to show me the features, so I put in Maunjaro just to see the prices, and I was pleasantly surprised. Keep in mind that these are THIS YEAR’S prices, as 2023 data won’t be live until October 15th. And I have ZERO idea what the requirements will be for prescribing it under these plans, and the requirements may differ between plans.
So this is what I saw for October 2022, for the highest dosage, which assumes I’m just starting in this plan for the last 3 months of the year, so it’s all pre-deductible (actually, all pre-donut hole since it appears the deductible doesn’t apply to this tier of medication), under the Cigna Extra Rx PDP plan (which happens to be the one Charles has this year), which has a monthly premium of $69.50 but only a $100 deductible:
October
WALMART PHARMACY 10-3604, Preferred in-network pharmacy, $42.00

SAFEWAY PHARMACY #1511, Preferred in-network pharmacy, $42.00

CVS PHARMACY #05791, Standard in-network pharmacy, $47.00
$47.00

WALGREENS #3657, Preferred in-network pharmacy, $42.00

Mail Order Pharmacy, Preferred in-network pharmacy, $126.00 (3 month supply)

Compare to this to the information from GoodRX, again:
2754

So it would be TOTALLY doable with a Medicare plan that covers expensive meds, IF it would also cover the prescription without limitations of proving diabetes or other requirements like failure with cheaper drugs.

Putting the drug into Cigna’s website and picking the same plan gave another interesting view:
Monthly Premium1
$69.50
Annual Deductible
$0 for Tiers 1, 2, 3 & 6
$100 for Tiers 4 & 5
Est. Retail Drug Cost2
$504.00
Total Est. Annual Cost
$1,338.00

That is freaking reasonable!!

Also, I noticed this:
2755

NO PRIOR AUTHORIZATION REQUIRED!!

I’m thinking it’s time to talk to my GI doctor about prescribing this for me, starting in January, and picking this plan. Although I noticed that my ADD and depression meds are MORE expensive on this plan than the Mounjaro. Weird. Still, if the Mounjaro helps me lose weight and keeps me from vomiting in the middle of the night, totally worth it.

Again, this is the plan Charles currently has, and we’ve already received notification that his insulin costs on this plan will be capped at $0/month or $35/month for next year, depending on which form he uses (I’m guessing his long-acting, once/day Lantus will have the $35 copay).

I will run the numbers again after October 15th to make sure they are the same or similar for 2023. But this is encouraging.
 

Spiky Bugger

Well-Known Member
Very hard to say, because it depends on your insurance and income, and likely your diagnosis, as well as how cooperative/creative your doctor is with coding.
  • There is a $25 copay plan, but you have to have regular (not Medicare/Medicaid) insurance and meet financial requirements
  • Some insurance covers it, at least for diabetes, but of course copays will vary
  • Most insurance companies adamantly do NOT cover weight loss drugs
  • I’m not sure how Medicare Part D plans will handle it, including what requirements they will require (do you have to have diabetes? do you have to have tried cheaper meds and failed?) and what the copays will be at each step of the pre-deductible, after deductible, donut hole, and catastrophic levels.
  • Also, starting in 2025, max copay for Medicare will be $2000, so that could make it good for anyone who can afford whatever the premiums will be.
  • However, yesterday I was talking to the guy who helps us figure out which Part D plan to pick for next year, and he told me Medicare now has a vastly improved website for doing it yourself, but he walked me through it to show me the features, so I put in Maunjaro just to see the prices, and I was pleasantly surprised. Keep in mind that these are THIS YEAR’S prices, as 2023 data won’t be live until October 15th. And I have ZERO idea what the requirements will be for prescribing it under these plans, and the requirements may differ between plans.
So this is what I saw for October 2022, for the highest dosage, which assumes I’m just starting in this plan for the last 3 months of the year, so it’s all pre-deductible (actually, all pre-donut hole since it appears the deductible doesn’t apply to this tier of medication), under the Cigna Extra Rx PDP plan (which happens to be the one Charles has this year), which has a monthly premium of $69.50 but only a $100 deductible:
October
WALMART PHARMACY 10-3604, Preferred in-network pharmacy, $42.00

SAFEWAY PHARMACY #1511, Preferred in-network pharmacy, $42.00

CVS PHARMACY #05791, Standard in-network pharmacy, $47.00
$47.00

WALGREENS #3657, Preferred in-network pharmacy, $42.00

Mail Order Pharmacy, Preferred in-network pharmacy, $126.00 (3 month supply)

Compare to this to the information from GoodRX, again:
View attachment 2754

So it would be TOTALLY doable with a Medicare plan that covers expensive meds, IF it would also cover the prescription without limitations of proving diabetes or other requirements like failure with cheaper drugs.

Putting the drug into Cigna’s website and picking the same plan gave another interesting view:
Monthly Premium1
$69.50
Annual Deductible
$0 for Tiers 1, 2, 3 & 6
$100 for Tiers 4 & 5
Est. Retail Drug Cost2
$504.00
Total Est. Annual Cost
$1,338.00

That is freaking reasonable!!

Also, I noticed this:
View attachment 2755

NO PRIOR AUTHORIZATION REQUIRED!!

I’m thinking it’s time to talk to my GI doctor about prescribing this for me, starting in January, and picking this plan. Although I noticed that my ADD and depression meds are MORE expensive on this plan than the Mounjaro. Weird. Still, if the Mounjaro helps me lose weight and keeps me from vomiting in the middle of the night, totally worth it.

Again, this is the plan Charles currently has, and we’ve already received notification that his insulin costs on this plan will be capped at $0/month or $35/month for next year, depending on which form he uses (I’m guessing his long-acting, once/day Lantus will have the $35 copay).

I will run the numbers again after October 15th to make sure they are the same or similar for 2023. But this is encouraging.
I sent this to MiniSue, her very good friend who is an MO RN, and that can’t be easy, and Mr. Sue…who lives at the cusp of overweight and obese, but has a dx of PRE-diabetes and LDL that’s too high in addition to his other health challenges/history. (We have a Medicare PPO w/decent Rx coverage, plus the VA. Again, if THEY carry it, it will probably cost $11.00)
 

DianaCox

Bad Cop
I just looked up the coverage on my current plan - price wise, it’s slightly better: $40), BUT:
Mounjaro 15mg/0.5ml solution pen injectorTier 3YesYes
The “yeses” are for preauthorization required and quantity limits.

So I might wait until January to avoid that hassle. But I will start the process with my GI doc on the 13th when I see him for my EGD.
 

Spiky Bugger

Well-Known Member
So, results?

I did not read this slowly enough to understand it. I DID notice that they apparently grouped the results of ALL bariatric surgeries together, giving a result of like 25%. (Weight loss or excess weight loss?)

Study participants included pre-diabetics…but FDA will look at T2D pts only?

After the 72 weeks (which my brain kept changing to “72 months,” lol), then what? Do we know what happened when treatment stopped? And since the study took place DURING the beginning of the pandemic, seems to me that not enough time has elapsed to have an idea of what to expect two, three, five years out.

Am I out in left field on all these concerns?
 

southernlady

Administrator
Staff member
Diana, before doing this, read all side effects carefully. There are times when the cons outweigh the pros, but just read them carefully. Especially since one side effect is nausea.
 
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DianaCox

Bad Cop
Coming back to this thread to share this, which is interesting:

“A decades-old law prohibits Medicare from covering prescription drugs to treat weight gain or weight loss. That means the roughly 49 million people in the U.S. who get their prescription drug coverage from Medicare would have to spend more than $1,300 a month for a Wegovy prescription, putting access far out of reach for many. Even for people with private health insurance, these drugs may not be covered. Less than 10% of people have commercial health insurance that covers weight-management therapies like Wegovy.

But an aggressive lobbying push in Washington and quiet support in different parts of the Biden administration indicate that the longstanding rule is being reconsidered. The House Appropriations Committee in June described Medicare coverage for obesity drugs as a “matter of health equity.” The Office of Personnel Management, the federal government’s human resources department, this year reiterated that obesity drugs can’t be excluded from insurance plans for federal workers. “The bottom line is that we follow the science and, in this instance, the science is telling us that we should recommend uptake of anti-obesity drugs more strongly than we did previously,” an OPM spokesperson told MarketWatch.

This line of thinking suggests that “additional federal coverage may not be far behind,” said UBS analyst Colin Bristow.”
[URL='https://www.marketwatch.com/amp/story/theres-no-way-that-patients-are-going-to-be-able-to-afford-that-why-arent-new-drugs-that-can-help-you-lose-weight-more-widely-used-11664719259']‘There's no way that patients are going to be able to afford that.’ Why aren’t new drugs that can help you lose weight more widely used?
marketwatch.com
[/URL]


As for the questions and comments above:

Yes, nausea is a potential side effect - but it likely occurs because of the delay in gastric emptying. But nausea (and the delay in gastric emptying?) may only be transitory.

And yes, it may be required to take it continuously - like it would be required for diabetes. Because obesity is also a metabolic disease.

I asked my GI doc if he would prescribe it - he would not. I asked Charles’ endocrinologist, and their response was that they aren’t taking new patients (I could have argued that they should make an exception, but I don’t want to mess with his relationship with that office, which is close to us and highly regarded). I asked my PCP, and his office said they were not prescribing it (yet?). I called the bariatric surgeon’s office of the one surgeon I would go to if there was an emergency with my guts and I couldn’t get back to California to either Rabkin or Keshishian, Dr. Arnold, and they invited me to come in first for an appointment because it’s been over a year since my intro appointment with him.

So I made a post on my community Egroup to ask if anyone had a doctor prescribing Mounjaro for them, and got a name. I have an appointment with him later this month.

In the meantime, I did a comparison on the Medicare website of Part D plans. If I stay on my current plan (which was optimized last year without Mounjaro of course), and add this drug to my regimen, my full year costs (premiums, deductible and drug costs for 12 months) for next year would change from $3173/year to $17,207/year. But if I switch to a different plan, which costs more per month for the premium, but has a much smaller deductible, the full year cost is $5016.

If I stay on my current plan, just for this drug: $14,036.04

On the other plan: $2,000.83

At a retail pharmacy, using GoodRX, it’s about $1000/28 days. So $13,000/year.

And also, the FDA has fast-tracked tirzepatide for obesity: https://investor.lilly.com/news-releases/news-release-details/lilly-receives-us-fda-fast-track-designation-tirzepatide
 

hilary1617

First time at the rodeo.
While not Mounjaro, my son has been on Ozempic since December and is nauseous for a few days after each injection, and he has had to supplement with magnesium for gi impacts of slowed emptying...

He's also on multiple other medications for his Cushing's disease, so hard to sort out which side effect is from which medicine, but he definitely has challenges post-Ozempic shot that are different from other days.

FWIW, I feel your pain on the prescription / prescribing / insurance front. We just received a denial from my insurer for his primary medicine, Isturisa/Osilodrostat, which he has been on since February and is improving his condition. Isturisa runs about $140 per pill, which he takes twice daily - insurance wants him to stop Isturisa and start monthly Signifor/Pasireotide injections instead- and only move back to Isturisa if Signifor doesn't work for him... It's strange, because Signifor has to be administerd by a medical professional and is equally or more expensive than Isturisa. Our doctor is appealing that decision, but it is super-frustrating.
 
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