Hype or Help? Weight Loss Drug Considerations for Employers

Viewpoints from Sarah Fleming & Erin Milliken

Coauthored by Sarah Fleming, PharmD – Senior Pharmacy Benefit Clinical Consultant at PSG, and Erin Milliken, MPH, CHES – Director, Wellbeing and Health Management Solutions at EPIC

With obesity impacting over 42% of adults and driving over $173 billion in annual medical costs in the U.S.¹, incorporating a holistic wellbeing strategy has become more meaningful than ever to employers. Adding anti-obesity medications, specifically GLP-1s, into this overarching strategy continues to gain momentum

Recent regulatory changes have further amplified the pressure on employer health plans to respond.

The Food and Drug Administration (FDA) has approved an expanded indication of Wegovy (semaglutide) to reduce the risk of major cardiovascular events for individuals who are either obese or overweight with established cardiovascular disease. Then, the CMS (Centers for Medicare and Medicaid Services) announced that health plans under Medicare Part D could cover Wegovy when deemed medically necessary. These developments underscore the growing importance of GLP-1 medications in healthcare management.

While the cardiovascular and weight loss data emphasize the potential benefits of GLP-1 medications, the financial impact – potentially as much as $18,000 annually – has made coverage decisions challenging for employers.

Additionally, clinical trial data shows that continuous, chronic use is required to maintain weight loss. In people who discontinued therapy, two-thirds of their lost weight was regained after one year. Employers have also voiced their concerns regarding the potential side effects of these medications and their impact on member adherence.

If an employer elects to add coverage for weight loss, however, there are steps to manage GLP-1 medications effectively.

The EPIC Pharmacy Solutions Group recommendation is to take an active approach to monitor ongoing utilization and to consider the following tools:

• Formulary Management and Rebate Assessment to prevent potential off-label utilization.
• Assessing Member Cost Shares, including proper tiering and evaluating manufacturer copay assistance plans.
• Increasing Body Mass Index (BMI) Requirement focusing on members who may benefit most from coverage. Currently, the World Health Organization classifies:
  • Grade 1 overweight (overweight): BMI of 25–29.9 kg/m²
  • Grade 2 overweight (obesity): BMI 30–39.9 kg/m²
  • Grade 3 overweight (severe/morbid obesity): BMI >40 kg/m
• Custom Utilization Management: This includes a requirement of participation in a wellness program with health coaching and outcomes monitoring to complement coverage of weight loss medications.

More detailed information and overall coverage considerations can be found here to help employers build a thoughtful strategy around weight loss coverage.

In addition to the recommendations above, EPIC encourages employers to take a step back – to truly understand the underlying cause of such high overweight and obesity rates in this country and among employee populations.

It is important to recognize that GLP-1 medications, while formidable weapons, are just one component in the battle against obesity and obesity-related conditions. Truly, the best answer to losing excess weight (or body fat) and keeping it off is to make small, healthy changes in your eating and exercise habits. Managing weight is a life-long commitment. Employers can support their employees by implementing wellbeing initiatives (that may include point-solution vendors) and strategies to assist in making good, healthful decisions in the workplace. To learn more, contact the EPIC Wellbeing & Health Management team.

To assist in matching these solutions to our clients’ specific circumstances, EPIC has extensively evaluated potential vendors and resources.

This strategy includes integrated health plans and independent point solutions focused on behavior modification and medication management. Through an initial questionnaire that assesses variables such as client size, customizable clinical capabilities, and performance guarantees, we are able to narrow the available vendors to one best suited to your and your employees’ unique needs.

Download our overview through the form on this page to connect with a consultant and set up your complimentary Custom Weight Loss Solutions Analysis.

References:

1. Adult Obesity Facts | Overweight & Obesity | CDC

EPIC offers this material for general information only. EPIC does not intend this material to be, nor may any person receiving this information construe or rely on this material as, tax or legal advice. The matters addressed in this document and any related discussions or correspondence should be reviewed and discussed with legal counsel prior to acting or relying on these materials.