espite the fact that approximately 2.74 million patients used anti-obesity drugs in 2011, according to information services company IMS Health, the majority of health plans are following the lead of the Centers for Medicare and Medicaid Services and not covering them.
Despite the fact that approximately 2.74 million patients used anti-obesity drugs in 2011, according to information services company IMS Health, the majority of health plans are following the lead of the Centers for Medicare and Medicaid Services and not covering them.
More than one-third of adults (34.9%) and 17% of youth in the United States are obese, according to the Centers for Disease Control and Prevention (CDC). The estimated annual medical cost of obesity in the U.S in 2012 was $190.2 billion, or nearly 21% of annual medical spending, according to the
Journal for Health Economics, and the medical costs for obese people were $1,429 higher than those of normal weight, according to the CDC.
Caroline Apovian, M.D., professor of medicine and pediatrics at Boston University School of Medicine, attributes the small number of plans that cover weight-loss drugs to an historical perspective that obesity is a “matter of will power.” She applauds the American Medical Association for declaring obesity a disease last year, a decision hopefully “making many payers stop in their tracks.”
Apovian combines diet, exercise and weight-loss medications as treatment for her patients and says that most lose 5% to 10% of their body weight in six months to a year.
The high prices of obesity drugs, a lack of primary care physicians who specialize in treating obesity, and the fact dieticians are not reimbursed by most insurers are other factors keeping the drugs off many formularies.
Apovian notes that many health plans do reimburse physicians for counseling and treating obese patients with comorbidities during office visits, however.
Aetna is taking a pioneering step in the pharmacotherapy arena of weight-loss drugs. The Hartford, Connecticut-based insurer announced a pilot program in January to test the benefits of Qsymia (VIVUS) and Belviq (Eisai)--both approved in 2012--in conjunction with lifestyle support, for self-insured plan sponsors who choose to cover prescription weight-loss drugs. While there is no specific launch date, companies are expected to join on an ongoing basis through 2015. The pilot will measure potential improvement in health outcomes, productivity and medical costs.
More than 4,000 members currently have coverage for prescription weight-loss drugs and are eligible to participate in the pilot. By the beginning of 2015, Aetna expects more than 35,000 members will be eligible to participate. Members are eligible if they meet the body mass index (BMI) clinical requirements outlined for the two drugs (see “Third anti-obesity drug is approved for use in U.S.”, page 4) and have a doctor prescribe the medications. Other prescription weight-loss drugs may be covered, but only Belviq and Qsymia will be evaluated as part of the pilot.
In collaboration with the manufacturers of Qsymia and Belviq, the pilot offers outreach to high-risk members and doctors outlining covered weight-loss options. Members who qualify will also receive free premium membership to the mobile app “Lose It!” by signing up through Aetna Navigator and CarePass.
“Weight loss is a complex, physical and emotional challenge,” says Ed Pezalla, M.D., national medical director for pharmacy policy and strategy at Aetna. “A single approach to weight loss will not be right for everyone.
“We want to help our members make healthy lifestyle choices with their doctors by providing access to clinically proven options, information and support that may deliver better results and new hope for those struggling to lose weight,” he says. “At the same time, plan sponsors have the option to cover these prescription weight-loss medications in Aetna’s health benefit plans. We are conducting the pilot to give plan sponsors more information about the potential value of weight-loss drugs.”
Pezalla says that the majority of self-insured employers do not offer coverage for prescription weight-loss drugs. If they do elect coverage, the medications may be subject to coverage for medical necessity only and require preauthorization following a set of requirements.
Patients using Belviq and Qsymia also require reauthorization at 12 weeks. Patients taking Belviq have to show a documented weight loss of at least 5% of baseline body weight. For Qsymia, the requirement is at least 3% of baseline body weight.
For companies in the pilot who do cover weight-loss drugs, the medications are available on tier 2--preferred branded drugs--through retail and mail order pharmacies.
If the drugs are covered under the medical benefit, they are reimbursed through a weight-loss rider. Aetna plans to evaluate results in the next 12 months.
Determining if weight-loss drugs should be covered by insurers is definitely not cut and dried, says Andrew Behm, Pharm.D., vice president of clinical evaluation and policy for Express Scripts, a St. Louis-based pharmacy benefits manager.
Although he says the obesity epidemic has grown and Express Scripts’ clients are more open to drug and non-drug related solutions, the high cost of these medications, along with uncertain benefits for health and productivity, need to be weighed carefully before coverage decisions are made.
The price for a 30-day supply of Belviq and Qsymia, using coupons or discounts from their manufacturers, ranges from $110 to $178, according to GoodRx.com.
“The potential benefits of these new anti-obesity medications need to be compared against their risks and cost,” Behm says.
“In light of these shortcomings, plan sponsors have a variety of ways that they address weight-loss medications,” Behm says. “At Express Scripts, we commonly see three approaches: outright coverage without any restrictions, outright benefit coverage exclusion; and perhaps the most common approach, drug therapy coverage as long as the patient meets specific body mass index requirements, plus or minus specific risk factors, and is actively engaged in behavioral modification and/or restricted caloric intake.”
He notes that all of the current medications provide relatively marginal weight loss results for the vast majority of patients, and the initial weight loss benefits are frequently not sustained over an extended period--even for patients who adhere to drug and lifestyle changes.
Behm does not view weight-loss medications and bariatric surgery as competing therapies because drugs only reduce weight in the range of 3% to 10% when used in combination with lifestyle modifications. On the other hand, most patients eligible for surgery are often several hundred pounds over their ideal body weight. Instead, he says, physicians likely will guide patients to the appropriate solution based on the patient’s baseline BMI.
Apovian, along with other healthcare professionals and the Obesity Society, are trying to make legislators aware of the potential for diet, exercise and medications to reduce the cost of healthcare by preventing chronic diseases such as diabetes. So far, their efforts have been unsuccessful.
Mari Edlin is a freelance writer based in Sonoma, Calif.