— Studies suggest coverage is warranted for certain populations
by
Nancy K. Klotz, MD, MBA
January 16, 2024
Klotz is Chief Medical Officer at a third-party health benefits administrator for self-insured employers.
Since the NIH started measuring obesity prevalence in the U.S. 60 years ago, the rates have tripled, with more than 42% of American adults considered obese and another 31% overweight. As excess weight is linked to chronic conditions like diabetes, hypertension, and congestive heart failure, healthcare providers and patients alike are looking for long-term solutions to reduce risks.
Treatments for obesity have historically been expensive and invasive (such as bariatric surgery), or ineffective, deterring insurers from addressing obesity as a chronic condition. But when Eli Lilly’s tirzepatide (Mounjaro) and Novo Nordisk’s semaglutide (Ozempic) hit the market to fight diabetes, these drugs also achieved impressive weight loss results for diabetic patients with obesity. Despite their indication for patients with diabetes, many people have been using these drugs off-label to accomplish significant weight loss unrelated to diabetes treatment.
Yet, with an increasing number of FDA-approved GLP-1 receptor agonists indicated for overweight or obesity — the latest approval being tirzepatide (Zepbound) — the question still remains: Will these drugs be covered by insurance? In cases where health plan sponsors (employers) contract with a full-risk health insurance company, it’s up to the health insurance company to determine coverage. In other cases — for example, when self-insured plan sponsors contract with a third-party administrator — it’s up to the plan sponsor (or federal law).
Health insurance companies and plan sponsors are facing an important decision about whether to cover these drugs as a treatment for obesity.
Growing Interest in Weight-Loss Drugs
In a recent poll, the Kaiser Family Foundation found that nearly half of adults (45%) say they are generally interested in taking a prescription weight-loss drug, but that percentage drops to 16% if the medication is not covered by insurance.
These drugs are expensive; retail prices average around $1,000 for a month of injections. But the results are hard to ignore. In one clinical study, tirzepatide helped patients lose an average of 26.6% of their body weight following extended use and lifestyle changes. Unlike previous studies, these trials excluded people with type 2 diabetes.
The benefits of tirzepatide and semaglutide extend beyond weight loss to the improvement of other health conditions. In November 2023, another clinical study showed that semaglutide can reduce the risk of heart attacks and stroke by 20% for adults with heart disease and obesity.
Studies like these support the proposition that health plan coverage of the drugs is warranted.
Pay Now or Pay Later?
As most doctors and health insurers are aware, obesity is associated with a variety of health problems, including susceptibility to heart disease, stroke, and musculoskeletal issues. But is the investment in covering these drugs worth the benefit of improving long-term health? Weight-loss treatment offers the potential to protect against expensive and debilitating health conditions in the future, but what about the impact on costs now?
Currently, most private insurance and federal programs don’t cover drugs like tirzepatide and semaglutide for weight loss because of their high cost. Additionally, Medicare is prohibited by law from covering weight-loss drugs because of lingering safety concerns that stem from the legacy of drugs like fenfluramine and phentermine (fen-phen).
However, we advise approaching obesity as a chronic condition that requires long-term treatment and maintenance, including potential long-term or even lifetime use of drugs like semaglutide or tirzepatide. Notably, many physicians are now likely to prescribe weight-loss drugs in addition to weight management programs that include nutrition education, lifestyle changes, and behavior modification. Self-insured employers and insurance carriers must balance clinical and financial outcomes in making the decision on whether to cover these drugs for weight loss.
If health insurance carriers and self-insured employers decide that covering these drugs is in the best interest of their members, they may want to incorporate strict eligibility requirements.
For example, semaglutide (Wegovy) is intended for use by patients with a BMI of 30 or greater, or a BMI of 27 or greater and one weight-related health condition, such as high blood pressure. Recently, the FDA approved the use of Zepbound with the same eligibility requirements. When considering coverage of weight-loss drugs, health insurance carriers and self-insured employers may want to implement similar restrictions.
Because these drugs are so new, it’s hard to make a conclusive financial case that covering them is cost-effective in the long term. But given the clinical trials that show benefits far beyond diabetes control, the clinical case for covering weight-loss drugs, at least for certain populations, is becoming more compelling than ever.
Nancy K. Klotz, MD, MBA, is Chief Medical Officer at Brighton Health Plan Solutions, LLC, a third-party health insurance administrator that provides administrative services for self-funded health plans. She is responsible for clinical strategy across the company’s various business segments. Klotz is a fellow of the American College of Physicians.
