Ozempic, a drug approved for use to treat Type 2 diabetes in adults, has gained national attention as celebrities and TikTok influencers have touted its use for weight loss. This attention has generated unexpected demand and supply shortages for Ozempic and two other drugs that can lead to quick weight loss – Wegovy and Trulicity. Given the level of off-label use of these high-cost drugs, employers face some difficult decisions about how to cover them.
As has been well-reported, obesity is on the rise in the US and around the world. If not treated, it may result in greater risk of certain types of cancer, heart disease, type 2 diabetes and stroke, which all carry significant medical and economic costs. There are five FDA-approved prescription medications for chronic weight management: two injectable drugs (Wegovy and Saxenda), and three oral medications (Qsymia, Contrave and Xenical). The injectable medications are significantly more expensive but can be more effective with fewer contraindications.
However, some newer injectable weight-loss medications contain the same active ingredient as FDA-approved medications to treat type 2 diabetes. Plan sponsors that do not cover weight-loss medications are seeing some increased utilization of these diabetes medications, which are possibly being used for weight loss. Some pharmacy benefit managers (PBMs) have tightened their utilization management rules for select diabetes drugs to help manage the increasing utilization.
Coverage for weight-loss medication
Employer coverage of weight loss drugs varies; in recent data from a number of PBMs, prevalence of coverage in employer plans has ranged from 33% to 63%. Further, the use of prior authorization requirements among employers that cover weight-loss medications ranged from 50% to 80% across the PBMs.
There are identifiable, high-risk groups where treatment of weight management may have a greater clinical benefit, such as those with diabetes. Meaningful improvement in weight management can significantly slow disease progression and prevent complications. Clinical and cost-benefit impacts come from effectively reducing the progression of disease and development of comorbidities that ultimately contribute to high cost of care. On average, coverage of weight loss medication can add $2.25 to $2.60 per member per month.
Focus on better outcomes
For plans covering weight-loss medications, adding prior authorization criteria can help manage cost growth. These include requirements such as a certain body mass index (BMI), co-morbid conditions, enrollment in a behavior modification program, and/or reduced calorie diet. Upon initiation of therapy, patients and clinicians should partner to create a comprehensive plan to achieve goals and use the medication purposefully alongside a targeted and managed lifestyle program. The plan should include a discussion regarding medication discontinuation when/if goals are met to prevent relapse and weight regain/ weight cycling. Medical nutrition therapy (MNT) with a registered dietitian should be covered; ideally 14 in-person or telenutrition sessions.
Cognitive-behavioral therapy, self-monitoring, motivational interviewing, structured meal plans, portion control and goal setting are recommended interventions. Ideally, patients would progress from dietary intervention (covered MNT or weight management solution), to weight loss medications, and then, potentially, to bariatric surgery.
Thinking through your approach to weight-loss treatment
Now is the time to re-evaluate your overall benefit philosophy regarding coverage of weight-loss medications. Determine if coverage/exclusion of weight-loss medications and services is consistent across all benefits. If weight loss medications are not covered it could be time to consider coverage if your plan has a high prevalence of chronic conditions like diabetes. If weight-loss medications are covered, ensure members have access to programs that include counseling, coaching and nutrition support. Additionally, review your claims information and your PBM’s prior authorization program details (e.g., approvals/denials, criteria) to ensure the programs in place are effective. A review of your population data will aid in designing a holistic approach to improving the health and outcomes for members struggling with weight and the complications from obesity. Offering a comprehensive set of solutions that are aligned and integrated with medical and pharmacy plans will improve patient experience and outcomes.