Coverage of Medications for Weight Loss

Part 1

GBS has been experiencing an influx of questions from employers and plan members regarding the coverage of weight loss medications. More specifically, prescriptions for GIP/GLP-1 medications such as Wegovy, Ozempic, and Mounjaro.

Ozempic (semaglutide) and Mounjaro (tirzepatide) are approved to improve glycemic control in adults with type 2 diabetes (not for use in type 1 diabetes). These drugs also produce significant weight loss in the range of 15%-20% / 35lbs-50lbs. Wegovy (semaglutide – same active ingredient as Ozempic) was approved in 2021 for chronic weight management in adults with a BMI >30 kg/m2, or >27 kg/m2 with at least one weight related comorbid condition (e.g., hypertension, type 2 diabetes, or dyslipidemia).

Currently, most plans cover medications in the GLP-1 category (e.g., Ozempic, Victoza, Trulicity) for type 2 diabetes, often with prior authorization criteria (confirming type 2 diabetes). These drugs are typically not allowed for ‘pre-diabetes’ – with or without obesity as a co-morbidity. Many, if not most, carriers and employers do not cover weight loss medications.

While these medications are promising for weight loss, they’re not magic bullets, and all pharmacologic therapies should be considered as part of a wholistic approach to weight loss which may also include a healthy diet, exercise, and behavioral support.

This is an evolving market and one that is likely to change over the coming months and years as there are more approvals (like the weight loss indication for Mounjaro (tirzepatide)).

To support the market opportunity for these medications, manufacturers will be rolling out additional data to medicalize obesity and establish the medical and financial benefits of weight loss in certain at-risk populations (kidney disease, obstructive sleep apnea, morbidity / mortality in obesity).

The potential cost implications for widespread coverage of GLP-1’s for weight loss is significant with >40% of the US adult population being obese and an annual price tag approaching $15K per patient.

Covering weight loss medications is a plan decision. For now, we would suggest employers follow the lead of their carrier or PBM to manage these categories through recommended coverage and utilization management criteria, rather than approving one-off exceptions or overrides without a thorough clinical review.

Women around a table discussing work.

GBS will be providing more information on weight loss and multi-faceted management strategies in the near future.

In the meantime, if you have any questions, please don’t hesitate to reach out to your GBS Consultant or the GBS Population Health Team.

Part 2

In an effort to provide best practice, clinically-validated advice for our clients, our team has been diligent in learning about the efficacy of these medications from all perspectives – we’ve met with PBMs, health plans, condition management and clinical advocacy programs, engaged in discussions with clinical advisors, and heard perspectives from a number of practice groups specialized in patient care. We’ve even met directly with drug manufacturers.

The purpose of this article is to offer our clients a comprehensive understanding of our recommended strategy for addressing weight loss, with a specific focus on medications prescribed for weight loss.

We approach this topic from a population health perspective, emphasizing the importance of considering the overall well-being and health outcomes of a diverse group of individuals. It is important to recognize the distinction between a population health approach and a patient-specific care plan.

Each individual pursuing weight loss should be counseled with the pros, cons, side effects and cautions of the various options presented to them considering clinical need, quality of life, and patient preference, all while first and foremost being provided with ethical care. Because not every person pursuing weight loss is a candidate for weight loss medication, we do not recommend covering these drugs for weight loss based on weight status alone.

1. Education for informed decision-making is key.

This isn’t black and white. There’s no denying that these medications have a place in patient care. GLP-1 agonists, like Ozempic and Mounjaro, have been shown to have beneficial effects on a number of disease states, most notably diabetes and cardiovascular conditions, and have been used to do so for many years. But, between January and June 2023, 6 million prescriptions were written for off-label use for weight loss in the US! While they may have a place for patients seeking weight loss, more education and discussion around the pros, cons, and general goals for the patient are needed before placing someone on what is intended to be a lifelong medication.

asian businesswoman brainstorm conference with her partners discussing about financial budget new project analysis with tablet and printed charts document in meeting room

Significant side effects exist with GLP-1 agonists, including severe nausea, lack of appetite, associated muscle wasting and more, making it imperative to thoroughly evaluate benefits versus risks between a patient and provider as would occur with other prescription medications and treatment plans.

2. Clinical oversight is critical.

These are lifelong medications, meaning that the medication works only as long as the individual continues uses it. Individuals have options when it comes to weight loss (including taking a step back to decide if weight loss is even indicated). But for the sake of this piece, let’s say that weight loss is indicated as agreed upon by the patient and provider based on individual qualitative and quantitative data.

Three main categories of intervention are available:

  1. Lifestyle and Behavior Modifications
  2. Medication
  3. Surgery

The provider, ideally with training in obesity medicine, should oversee the ordering, duration, and decision process for these interventions in collaboration with other care team members for a wrap-around support of the patient.

3. Lifestyle changes must be co-prescribed and adhered to for sustained results.

With the goal of using the least invasive means available, lifestyle intervention should always be a precursor to medication and surgery. As the first line intervention, lifestyle changes will be enough for most people to achieve improved health markers whether or not weight loss is achieved.

Research shows that the overwhelming majority of weight loss attempts do not result in long-term weight loss, and actually result in a higher body weight from when weight loss was initiated. But structured behavior modifications improve both health and quality of life regardless of weight status. With or without medication for weight loss, specific lifestyle interventions include:

1. Nutrition counseling to optimize dietary intake for preventing muscle loss and maximizing nutritional profile to best support health and prevent illness.

2. Therapy to address underlying maladaptive behaviors that have resulted from mental health concerns such as depression, stress, and/or trauma.

The empathetic mature adult therapist gestures and asks questions as he helps a younger man work through his problems.

3. Weight-bearing exercise to offset muscle and bone loss.

Our strong recommendation is for employer health plans to require the completion of a lifestyle intervention/behavior modification program as an initial authorization for weight loss medication coverage.

This is not dissimilar to bariatric surgery, in that standard eligibility criteria includes completion of a weight loss program and/or proven attempts at weight loss, typically through nutrition therapy with a registered dietitian at minimum, and those interventions having not resulted in sustained weight loss. In addition, we recommend authorization for medication, once qualified, include enrollment in a behavior/lifestyle support program to remain eligible for the medication.

Lastly, a reauthorization process should require documented weight loss and proof of participation in a behavior modification program after 6 months on the drug.

We understand that controlling how these medications are prescribed and managed by a member’s provider(s) is impossible at the plan level.

Partnering with a lifestyle intervention program to support members who are seeking weight loss is a win-win for all stakeholders involved, including members, employers and healthcare providers. Plan members will be more likely to see health improvements through engaging in a lifestyle intervention with or without weight loss and more likely to maintain results if medication is started.

Employers will see a better use of their investment as not all members will end up on medication, and those who do will be more likely to maintain long-term results. Healthcare providers, through collaboration with lifestyle intervention programs, can be assured that patients receive both medical and lifestyle support, leading to better outcomes and reduced medication reliance when possible.

If you have any questions, please don’t hesitate to reach out to your GBS Consultant or the GBS Population Health Team.

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