Their child’s obesity drug was working. Then their plan refused to pay.

A Connecticut family faced coverage denial for their daughter’s off-label use of Ozempic, a medication that helped her lose weight. Ozempic was prescribed to Debra Tyler’s second daughter at the risk of liver failure when she was 11 years old, and cholesterol-lowering medications were prescribed to her by the time she was eight.

Before Ozempic, the Tyler family tried everything, including diet plans, exercise plans, and counseling. The Tylers were left with an $831 bill for a month’s worth of treatment because their insurer refused to cover the $1,331 per month treatment for the girl’s off-label use.

Over 14.4 million children in the United States have been diagnosed with obesity, and related health issues like Type 2 diabetes and fatty liver disease are significant and growing problems. Numerous factors, including diet changes, inactivity, and genetic predisposition, have been linked to this trend. Effective treatments for childhood obesity remain elusive, and many families struggle to pay for care despite growing awareness of the issue.

The Tyler family’s story is just one illustration of how difficult it can be for families to find the right care for their children. The FDA has approved Ozempic for adults, but its use in children is still off-label, so insurance companies are not required to pay for it. In addition, even when a medication is covered by insurance, the high costs of deductibles and copays can still be a significant financial burden for families.

The majority of uninsured American families cannot afford potentially game-changing medications because of their high prices. Only 30 to 40% of commercial health insurance plans and 19 Medicaid programs cover anti-obesity medications at some level, according to a 2022 Urban Institute report. Because there isn’t enough coverage, many families have to choose between going into debt to pay for care or not getting it at all.

Changes in diet and physical activity, as well as novel treatments that are both safe and effective for children, will ultimately be necessary to address the issue of childhood obesity. However, as the Tyler family case demonstrates, insurance companies’ and drug manufacturers’ approaches to pricing and coverage will need to change in order to guarantee access to these treatments. Many children will continue to face obstacles to receiving the care they require to maintain optimal health unless such changes are made.

56 thoughts on “Their child’s obesity drug was working. Then their plan refused to pay.

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