Our association with Pharmacy Strategies Group (PSG) has made me even more acutely aware of the importance of proactive pharmacy consulting in managing overall healthcare costs. For years, I have been writing in the abstract that specialty pharmacy costs are the fastest-growing component of healthcare expenses. Now, I feel like I am “armed for bear” with much more specific discussion points that give me greater insight into concurrent plan cost management.
Viewpoints from Craig Hasday
On June 24 (just days ago as I am writing this blog), the U.S. Food and Drug Administration (FDA) announced the approval of Wegovy, a new weight loss drug.
One in three Americans are dealing with chronic obesity and this drug has proved to help patients lose weight. During the clinical trial, 83.5% of patients achieved a weight loss of 5% or greater, with an average of 14.9%, over a little more than a year. The drug is approved for patients with a body mass index (BMI) of 30 or greater, or 27 or greater with certain weight-related comorbidities including type 2 diabetes, high cholesterol or high blood pressure. While I am not a diabetic, I would qualify – as would many people I know. But here’s the rub; the drug is expected to cost $1,300 per month or $15,600 annually. The impact on an employer’s health spend would be enormous.
Weight loss strategies have been undergoing utilization scrutiny for as long as I remember.
The most effective treatment, bariatric surgery, has been excluded by most plans as a lifestyle choice – but some plans do cover medically necessary bariatric surgery for patients who are morbidly obese. This means 100 pounds over recommended body weight and a BMI of 40 or greater. No doubt, this excess weight can lead to or aggravate serious medical conditions and become a health plan’s next large claimant. But bariatric surgery, which could be $50,000 or more with ongoing maintenance costs, seems much more intimidating than a weekly injection of Wegovy. Even still, I get several calls a year from human resources teams that struggle with employees who can’t understand why their health plan would not cover this procedure. About three million Americans are considered morbidly obese, which is less than 1% of the U.S. population.
My guess is that most plans will exclude Wegovy unless the patient is a confirmed diabetic.
Plans will likely include quantity limits that will restrict costs since tolerance of the drug will be an issue for many patients. With the help of PSG, EPIC consultants can start the conversation with their clients before the inevitable television and magazine ads. PSG makes us smarter and more effective consultants. If you are not getting this insight from your current consultant, give us a call.
Register for our Pharmacy Solutions webinar with PSG on July 13 | Specialty Spend Is on the Rise Again
EPIC offers these opinions 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 article and any related discussions or correspondence should be reviewed and discussed with legal counsel prior to acting or relying on these materials.
Sign up for our EPIC Viewpoints Newsletter
You’ll receive semi-monthly alerts about candid perspectives on the employee benefits and risk management landscapes
President, National Employee Benefits Practice