Introduction
For years, commercial health insurers have hesitated to cover anti-obesity drugs, often labeling them as “lifestyle” treatments rather than true medical therapy. Patients who wanted access to new medications like Wegovy or Zepbound often faced denials, high out-of-pocket costs, or restrictive prior authorization rules. That picture is now beginning to change, thanks to a pair of pivotal FDA decisions in 2024.
First came Wegovy’s (Wegovy (semaglutide)) new approval for reducing cardiovascular risk in adults with obesity or overweight who also have heart disease. Then, later in the year, Zepbound won approval for treating obstructive sleep apnea (OSA) in adults with obesity. These “non-metabolic indications” matter because cardiovascular disease and OSA are already recognized by insurers as costly, high-burden conditions. Covering a drug under those diagnoses is very different from covering it simply for weight loss.
Early signals suggest insurers are paying attention. Some have started to update formularies or add exceptions tied specifically to these new FDA indications. Industry analysts, media reports, and health policy experts see this as the beginning of a broader shift: obesity drugs moving from the “optional” category toward the mainstream of disease management.
FDA Approvals and the “Non-Metabolic” Pivot
By approving Wegovy for cardiovascular risk reduction and Zepbound for obstructive sleep apnea (OSA), the FDA gave these medications a new identity: treatments for serious, high-cost conditions that insurers already prioritize. Until now, most anti-obesity drugs were categorized as “weight-loss” therapies. That label, whether fair or not, has been a barrier. Insurers often treat weight-loss treatments as elective, lumping them in with cosmetic interventions rather than essential healthcare.
Take Wegovy’s cardiovascular approval first. The evidence comes from the SELECT trial, which showed that semaglutide reduced the risk of major adverse cardiovascular events like heart attack, stroke, and cardiovascular death by about 20% in adults with obesity or overweight and pre-existing cardiovascular disease.
Now look at Zepbound’s OSA approval. Obstructive sleep apnea has long been recognized as a condition that costs insurers dearly. When tirzepatide was shown in the SURMOUNT-OSA trial to significantly reduce the apnea-hypopnea index (AHI) in adults with obesity, the FDA gave it the first-ever approval of a drug for OSA tied directly to weight reduction.
The so-called “non-metabolic” pivot, i.e., the movement of obesity drugs into indications for cardiovascular disease and OSA, marks a turning point. It reframes the conversation from “should insurers cover weight-loss drugs?” to “can insurers afford not to cover drugs that reduce heart attacks and sleep apnea complications?”
Commercial Insurer Responses and Emerging Coverage Policies
The pattern is one of conditional acceptance: Wegovy and Zepbound are starting to be covered when prescribed for cardiovascular disease or OSA, but rarely for obesity alone. Several large insurers have already signaled a willingness to expand coverage for Wegovy when prescribed for cardiovascular risk reduction. Reports in late 2024 and early 2025 describe policy adjustments that explicitly require a documented cardiovascular diagnosis, such as prior heart attack, stroke, or established atherosclerotic disease.
The same dynamic is unfolding with Zepbound and OSA. Early statements from national payers suggest coverage is being extended to patients with moderate-to-severe obstructive sleep apnea, verified through a sleep study. Prior authorization is nearly universal, often requiring proof that the patient has OSA, a BMI above the obesity threshold, and in some cases a history of difficulty tolerating CPAP.
Provider networks are also adapting. Cardiologists and sleep specialists are being briefed by insurers on documentation requirements for prescribing. Coding and documentation now determine access: a patient prescribed Wegovy under “obesity” might face denial, while the same prescription under “cardiovascular risk reduction” could be approved.
Broader Implications for Patients, Providers, and the Market
For providers, the new approvals and insurer policies reshape how care is delivered. Cardiologists and sleep specialists suddenly find themselves as key prescribers of drugs once confined to obesity clinics or endocrinology offices. That’s a significant shift in clinical workflow. It also means these specialists need to become familiar with GLP-1 and GIP/GLP-1 agents—their side effects, dose adjustments, and insurance paperwork.
Pharmaceutical companies, particularly Novo Nordisk and Eli Lilly, stand to benefit. By reframing their products as treatments for cardiovascular disease and OSA, they gain not just scientific credibility but also expanded payer coverage. Analysts estimate these approvals could add billions in potential sales, as new patient populations become eligible. Still, high drug prices remain a lightning rod. Media coverage and policy analysts from HHS and ASPE are already asking whether expanded coverage will inflate premiums and strain employer health budgets.
Conclusion
The FDA’s 2024 approvals of Wegovy for cardiovascular risk reduction and Zepbound for obstructive sleep apnea have done more than add new lines to drug labels—they’ve reshaped how commercial insurers think about covering anti-obesity drugs. By tying these therapies to serious, high-cost conditions that insurers already recognize as medical priorities, the approvals created a new logic for coverage.
For patients, the shift means more opportunities to access life-changing therapies, though only if they meet specific diagnostic criteria. For providers, it broadens the range of specialists involved in prescribing, while also increasing the burden of coding and documentation. For the pharmaceutical industry, it represents a major win, opening up markets that were once locked behind “lifestyle” exclusions.
Still, coverage expansion is selective and cautious. Insurers are balancing the promise of long-term savings against the immediate costs of drugs priced at more than $1,000 a month. Employers and policy analysts are watching closely to see whether broader adoption will drive up premiums.
As of 2025, “non-metabolic” indications are the wedge driving change. Whether this momentum leads to full normalization of obesity pharmacotherapy or stalls under financial pressure will be one of the key healthcare questions of the next decade.
References
- Food and Drug Administration. (2024, March 8). FDA approves first treatment to reduce risk of serious heart problems specifically for adults with obesity or overweight. U.S. Food and Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-reduce-risk-serious-heart-problems-specifically-adults-obesity-or
- Food and Drug Administration. (2024, December 20). FDA approves Zepbound for the treatment of obstructive sleep apnea in adults with obesity. U.S. Food and Drug Administration.
https://www.fda.gov/news-events/press-announcements
