Weight Loss Treatment Drugs

Kayla Clark, National Director, Clinical Pharmacy, HUB International
Matthew Moore, Regional Pharmacy Consultant, HUB International

Recently, GLP-1s (glucagon like peptide-1 receptor agonists) have gained notoriety in the news and social media as effective treatments for weight loss or diabetes. While treating diabetes is something employers are very accustomed to, thinking about coverage for medication-assisted weight loss are newer concepts for many – and have prompted a more complex decision-making process.

Here are three key pharmacy benefits considerations for obesity treatment drugs:

COVERAGE AS A CLASS OF MEDICATION

Although there are pros and cons to each type of anti-obesity medication (AOMs), GLP-1s have proven to be more effective¹, at least short term, at reducing weight compared to other AOMs, which has led to their popularity. GLP-1 medications indicated for weight loss – such as Saxenda™, Wegovy™ and Zepbound™ – are also much more expensive than other AOMs on the market that assist with weight loss and must be paired with behavior modification, exercise and other lifestyle adjustments.²

Today, self-funded employers generally have the option to cover or exclude AOMs as part of their benefit plan. If an employer elects in favor of coverage, the entire category of products indicated for weight loss will be covered subject to PBM and carrier formulary rules, not just GLP-1s. Employers looking at adding coverage need to carefully understand the options and cost implications for their population. Subject matter experts at HUB are trained to help employers use demographic, clinical and other plan insights to make informed decisions about coverage of these medications.

INTEGRATION WITH EXISTING BENEFITS

In general, coverage of AOMs for weight loss will have little conflict or overlap with other health and wellness offerings. However, to maintain a consistent message, employers should confirm how weight loss or bariatric surgery is covered on the medical plan, and if so, what type of criteria or coverage protocols are required.

Employers should also be aware of wellness vendors’ point of view on weight-loss support programs. Some vendors specifically advocate weight loss without medication and are actively “deprescribing” medications as part of their program, whereas others have a medication-assisted approach. HUB subject matter experts can review and compare program attributes, as well as develop client-specific communications to support the announcement and appropriate use of these programs.

LONG-TERM WORKPLACE WELLNESS CONSIDERATIONS

The health detriments of obesity are well known and far reaching. There are likely additional social, emotional and mental health costs that are not easily measured.³ So, it is no wonder that these promising new weight-loss medications have captivated our attention and are causing plan sponsors across the country to carefully revisit this topic.

Many employees will see coverage of weight-loss medications as an additional perk that will be perceived as a great enhancement to the benefits package, sending a strong message that the employer is willing to invest in their long-term health and wellbeing. However, the expense of covering these medications, as well as the overall long-term benefit, requires careful plan evaluation.

¹ National Library of Medicine, “Comparative effectiveness of GLP-1 receptor agonists on glycaemic control, body weight, and lipid profile for type 2 diabetes: systemic review and network meta-analysis,” January 29, 2024.
² The New York Times, “Buried in Wegovy Costs, North Carolina Will Stop Paying for Obesity Drugs,” January 26, 2024.
³ Economist Impact, “Social determinants of health and obesity,” accessed August 7, 2024.

Cory Jorbin, Director of Compliance Consulting, National Employee Benefits, HUB International

Many employer-sponsored plans are debating whether to cover weight loss medications under their plans and, if so, what guardrails to put in place to help manage utilization and plan expenses.

Here are 3 key compliance considerations for obesity treatment drugs:

REGULATORY COMPLIANCE

The only obesity related coverage that is currently REQUIRED falls under the Affordable Care Act (“ACA”) which incorporates the US Preventive Services Task Force A and B recommendations. Non-grandfathered health plans must cover at 100% screening for obesity in adults, and intensive, multicomponent behavioral interventions for weight management for those with a BMI of 30 or higher. However, this does not require specific coverage for actual weight loss treatment or medications.

In other words, while there’s no law in place preventing an employer from covering weight loss treatment drugs, no laws require them to do so.

NONDISCRIMINATION AND INCLUSION

There are 3 bodies of law governing nondiscrimination and inclusion—the Americans with Disabilities Act (ADA), the Genetic Information Nondiscrimination Act (GINA), and HIPAA.

ADA regulations include very specific language prohibiting plan designs – often called exclusions and limitations – from discriminating on the basis of an ADA-qualifying condition.

Some courts have determined severe obesity to be a physical impairment, while others have held it to be an impairment under the ADA ONLY if it’s the result of an underlying physiological disorder or condition. Because of this, we recommend consulting with counsel for specific legal advice on the ADA.

GINA protects employees from discrimination based on genetic information – which obesity may relate to.

For example, an employer could not reassign someone whom it learned had a family medical history of heart disease from a job it believed would be too stressful and might eventually lead to heart-related problems for the employee.

This means that a uniform and consistent exclusion for obesity drug coverage across a plan – as long as it’s not individually applied – MAY NOT run afoul of GINA.

HIPAA protects employees from discrimination on the basis of health factors. HIPAA states that any restrictions on benefits must apply uniformly to all similarly situated individuals and must not be directed at individual participants or based on the health factor of any one individual.

What all of this means for weight loss drugs is that any decision to exclude these medications must be applied uniformly across an organization.

A fourth area of law, the Mental Health Parity and Addiction Equity Act (“MHPAEA”) may also play a role in certain instances. MHPAEA requires plans to treat mental health/substance use disorder benefits in parity with medical/surgical benefits. While MHPAEA doesn’t require plans to cover weight loss medications, it may play a role if an individual is prescribed such a medication in connection with an eating disorder.

ACCESSIBILITY AND AFFORDABILITY

If a plan covers weight loss treatment drugs, participants will get the benefit of the negotiated rates. However, since these medications are newer and generics are not yet available, negotiated rates may still be costly, particularly in high deductible health plans.

Weight loss drugs are expensive—for employers and employees alike. Tools like Health Savings, Flexible Spending and Health Reimbursement Accounts may help manage costs, or at least provide some tax benefits in paying these costs.

Kirsten Bot, National Director, Actuarial Services and Financial Consulting, HUB International
Kayla Clark, National Director, Clinical Pharmacy, HUB International

Obesity costs the U.S. healthcare system an estimated $173 billion annually,¹ with some surveys estimating an obese patient will incur more than $2,000 more per year in medical costs than a healthy individual.² When considering anti-obesity medication (AOM) coverage, it is important to consider all costs as well as return on investment in long-term employee health and wellness and dollars spent. The question moving forward is not just “should we cover these medications?” but “how should we cover these medications?”

Here are three key cost and implementation considerations for AOMs:

DIRECT COST OF IMPLEMENTATION

Today, glucagon like peptide-1 receptor agonists (GLP-1) medications for weight loss cost between $900 to $1,000 a month prior to plan discounts and rebates.³ It is important to review and understand PBM and carrier options available to manage appropriate access, utilization and deliver patient support. Subject matter experts at HUB are trained to help employers use demographic, clinical and other plan insights to make informed decisions about coverage of these medications. Our financial consulting and analytics teams have the tools to assist with pricing impact as employers consider covering these medications.

TANGENTIAL COSTS

Although AOM coverage will likely be viewed as a welcome addition by most participants, weight-loss drug coverage may lead to overall cost hikes, including long-term plan cost increases. In addition to implementing appropriate utilization management criteria, employers must also consider costs of additional wellness programs that may be needed to sustain weight loss with these medications. After one year of therapy, it has been found that 58% of users discontinue their medication for various reasons, such as side effects, cost and/or access to the medication.⁴ To capitalize on return-on-investment, it is imperative that employees are supported wholistically while they’re on GLP-1 therapy, so they can avoid weight gain once the medication is discontinued.

PERIODIC EVALUATION NEEDED

There are many GLP-1s in development as well as current medications being tested for additional FDA-approved indications.⁵ Current research includes using GLP-1s for some types of liver disease⁶ sleep apnea improvement⁷, neurological diseases (such as Parkinson’s⁸) and addiction treatment.⁹ Rely on HUB to help you navigate these coverage changes as the pharmacy benefit managers react to new indication approvals. As employers consider all the moving pieces of adding AOMs for weight loss, HUB is here to help you construct the right mix of benefit offerings to maximize your cost-avoidance and keep your employees happy and healthy.

¹ Centers for Disease Control and Prevention, “About Obesity,” January 23, 2024.
² National Institute of Health, “Association of body mass index with health care expenditures in the United States by age and sex,” March 24, 2021.
³ Forbes, “GLP-1 Agonists for Weight Loss: What You Need to Know,” updated September 25, 2023.
⁴ Journal of Managed Care & Specialty Pharmacy, “Real-world persistence and adherence to glucagon-like peptide-1 receptor agonists among obese commercially insured adults without diabetes,” May 8, 2024.
⁵ NBC News, “Beyond Ozempic: New GLP-1 drugs promise weight loss and health benefits,” June 23, 2024.
⁶ The New England Journal of Medicine, “Tirzepatide for Metabolic Dysfunction-Associated Steatohepatitis with Liver Fibrosis,” June 8, 2024.
⁷ The New England Journal of Medicine, “Tirzepatide for the Treatment of Obstructive Sleep Apnea and Obesity,” June 21, 2024.
⁸ The Lancet, “Exenatide once weekly versus placebo in Parkinson’s disease: a randomised, double-blind, placebo-controlled trial,” August 3, 2017.
⁹ National Institute of Health, “Glucagon-like peptide-1 receptor agonist, liraglutide, reduces heroin self-administration and drug-induced reinstatement of heroin-seeking behaviour in rats,” November 21, 2021.