All the Medicines We Cannot Have

COMMENTARY

My patient talks about carrying an extra person around—he is that much overweight—but still, he has been slow to embrace the idea of taking medication to help. Like so many individuals living with obesity, he blames himself because he does not exercise regularly and he does not always make healthy food choices. He sees medications and bariatric surgery as “cheating,” and he worries about potential adverse effects. But there are profound health implications when someone is 125 pounds overweight, and I feel strongly that he should give medication a try. I also believe that obesity is an issue of biology and culture and that blaming the victim is not helpful.

As a psychiatrist, and I do not generally prescribe glucagon-like peptide-1 (GLP-1) receptor agonists—medications such as Ozempic and Zepbound. But when he finally said, “Well, everyone else is getting thinner, I guess I could, too,” I jumped on the opportunity and wrote the prescription. I also thought I might have more energy than his other doctors for the upcoming battle to get the medication covered by insurance. At the local pharmacy, these medications cost between $650 and $1300 a month, if the patient bears the full cost. They can be purchased from the pharmaceutical companies without the autoinjector, for significantly less, but they still cost thousands of dollars a year if the patient self-pays.

Fortunately, my patient has good insurance, and Wegovy—the weight-loss version of Ozempic—is on the formulary of his pharmacy benefit manager (PBM), MedImpact. In addition to obesity, my patient has sleep apnea and fatty liver disease, giving him 3 US Food and Drug Administration indications for taking a GLP-1. I sent in the prescription, then filled out the prior authorization form.

The response, the denial, and the subsequent denial of my appeal were all swift. His PBM will approve coverage for obesity only if the patient has already had a cardiovascular event—a stroke, a heart attack, or peripheral vascular disease with well-defined parameters. There is no room in this equation for consideration of other comorbidities or for the emotional and social toll of severe obesity. PBMs are known for rigid guidelines; they are not known for having a heart.

Weight-loss medicines are not the only expensive medications patients struggle to access. Another patient I see has tardive dyskinesia—his tongue darts out of his mouth and he grimaces, a condition caused by a short course of an atypical antipsychotic. Fortunately, there is now a medication that can treat this condition. Deutetrabenazine (Austedo) has been very helpful to my patient, but it comes with a price tag of approximately $5000 per month, and not every patient with this condition can obtain it. The list goes on, and like every doctor, I have many stories of patients who have needed medications that insurance would not pay for. I have heard that it can be particularly difficult to get prior authorization for xanomeline/trospium (Cobenfy)—a novel combination medication that was approved for the treatment of schizophrenia in late 2024.

In the years since I graduated from medical school, the advances in medicine have been nothing short of miraculous. The most expensive medications we have are not those used in psychiatry, but one-time gene therapies for hereditary conditions such as hemophilia, Duchenne muscular dystrophy, and sickle cell disease—and these treatments cost millions of dollars. Treatments for other illnesses, such as disease-modifying therapies for multiple sclerosis, and medications for rare diseases like cardiac amyloidosis, can cost hundreds of thousands of dollars a year, and they may or may not be covered by an individual’s health insurance. Survival may come down to a policyholder’s crapshoot.

We like to think that when we get sick, we will be offered the most effective treatments with the fewest adverse effects. Sometimes those are the newest and most expensive options, and while everyone can see the advertisements, the best medications are often not accessible. In the case of the new weight-loss medications, many patients are paying for them out of pocket, making them one more form of social inequity, where the “haves” get thinner and healthier and the “have-nots” are excluded.

I do not have an answer, but I do sometimes wonder what the point is of developing medicines that patients cannot actually take. Medications can be extremely expensive to develop and health insurance premiums are already exorbitant.

It took 2 months and another appeal, but my patient was eventually approved for weight-loss medication. I was willing to do a lot of work for this and he was lucky to get the authorization; it seemed to be something of a fluke. It seems to me that if we are going to have miracle medicines, then they should be available to everyone who needs them.

Dr Miller is a clinical psychiatrist and writer in Baltimore. She is on the faculty at the Johns Hopkins School of Medicine.