Suffolk County imposes stricter rules for popular weight loss drug coverage
NEW YORK (PIX11) – There has been a lot of conversation lately about if new weight loss drugs like Wegovy and Mounjaro should be covered by insurance.
Now, in the new year, one of the biggest municipal health plans in the Tri-State Area is imposing stricter drug requirements.
"Our main priority is doing what is most healthy for people," said Suffolk County PBA President Louis Civello. "So in that view, these drugs should be a temporary solution to get people on the road to a healthier lifestyle."
Civello helped negotiate the new insurance rules for GLP-1 semaglutide weight loss drugs.
Beginning January 1st, the 47,000 public employees and their families on the Suffolk County Plan will need to have a body mass index of 32, which the National Institutes of Health considers obese, to get insurance coverage for weight loss medications.
People with a BMI above 27 may also qualify if they have other conditions like high blood pressure.
Everyone taking the drugs will also now be required to download a health app, do four monthly weigh-ins, and connect with wellness coaches.
"This is not punitive. We’re not looking to just take the drugs away," Civello explained. "We’re really looking for positive drug outcomes here. It’s not our jobs to maximize profits for drug companies. It’s our job to make sure our members have the healthiest outcomes possible."
Without insurance, semaglutide products can cost around a thousand dollars a month out of pocket.
That cost was also beginning to weigh on Suffolk County’s health plan.
In the Second quarter of 2022, it spent $1.2 million on GLP-1s. Two years later, in 2024, the number nearly quadrupled to $4.3 million.
The growing popularity of these drugs and their cost is becoming such a concern that this week, President Joe Biden proposed Medicare and Medicaid cover them.
That would shift a $35 billion burden onto the Federal Government. There have also been calls for drug makers to lower prices.
The incoming Trump Administration would ultimately have to finalize the Medicare and Medicaid rule change for weight loss drugs.