Starting next year, insurance companies, including Highmark, will implement new requirements for covering certain weight loss drugs. 

Highmark has announced an increase in the BMI threshold from 27 or 30 to 40 for GLP-1 medications like Wegovy and Ozempic in Buffalo and Central New York. This decision is based on clinical evidence regarding the effectiveness and safety of these medications.

Patients currently using these drugs may need re-evaluation by their doctors to continue qualifying for coverage. These changes reflect ongoing debates about the cost and accessibility of weight loss treatments in the U.S.

What You Need To Know

  • Insurance companies plan to change coverage requirements for weight loss drugs
  • Highmark will raise the BMI threshold for GLP-1 drug coverage 
  • Changes will affect patients in Buffalo and Central New York
  • Adjustments are based on clinical evidence and safety 
  • Patients may need to re-evaluation to maintain drug coverage 

For one woman on her weight-loss journey, a combination of surgery, exercise and the right medication made a significant difference. At least five days a week, Debbie Corie can be found at her local Planet Fitness.

“I try to do something every day," said Corie, who lost 120-plus pounds. "If I have something going on and I miss it, you know, Saturday, I come because it's a day over the weekend.”

Corie calls this a lifestyle and not a diet, noting that her life wasn’t always like this.

“Finally, I got to a point I reached my heaviest weight, which was 258 pounds," she said. "I was at the end of my rope.”

For her, that meant bariatric sleeve surgery, a procedure that reduces the size of the stomach to limit food intake.

“I lost 60 pounds rather quick, and then I gained some back but kept with it,” Corie said.

That’s when her doctor recommended trying the weight loss drug Wegovy.

“It's a pen. And you inject it either in your legs, or you can do it in your stomach,” she said.

Since 2017, Novo Nordisk, maker of the drugs Wegovy and Ozempic, report helping people reverse comorbidities as a result of weight loss.

But at the September Senate Health hearing, the CEO of the pharmaceutical company came under fire due to the high cost, citing Americans were paying 15 times more than their U.K. counterparts.

“It is not just an issue of economics," U.S. Sen. Bernie Sanders said. "It is not just an issue of corporate greed. It is a profound moral issue.”

The CEO said he’d be willing to discuss price reduction without affecting coverage. However, last year, some insurance companies reported they’d change the qualifications for the GLP1 drugs in several states.

Most recently, Highmark notified customers of a raise in body mass index threshold from 27 or 30 to 40, impacting people in Buffalo and Central New York at the start of next year. They said their decision was based on clinical evidence on the effectiveness and safety of weight loss medications, and were consistent with federal and state requirements.

Corie stopped using Wegovy a few years ago. But for those Highmark customers currently using the weight loss medications, they may need to be re-evaluated by their doctor to qualify for coverage.