Health+Benefits the March 2024 issue

Weight-Loss Drug Market Explodes

But not all payers are covering them.
By Sherree Geyer Posted on April 2, 2024

The prescription drug joins others approved by the FDA in the last 25 years for weight loss, including Xenical (orlistat), Qsymia (phentermine-topiramate), Contrave (naltrexone-bupropion), Saxenda (liraglutide) and Wegovy (semaglutide).

One drug that the FDA has not to date approved for use in weight loss is Ozempic, an injectable medication authorized for treating Type 2 diabetes. Nonetheless, some people are using the product to lose weight because of shortages of Wegovy and social media messaging about Ozempic’s effects, according to reporting in Forbes and other sources. Semaglutide is the active ingredient in Ozempic, though at a lower dosage than in Wegovy.

Forecasts show the obesity drug market reaching up to $100 billion or higher by the close of this decade, Reuters reported in January 2024.

Long-term use (meaning more than 12 weeks) of these drugs can help insurance plan members lose between 3% and 12% of total body weight, the Mayo Clinic says, especially when accompanied by a reduced-calorie diet and exercise. They are not to be used by pregnant women or by those trying to conceive and/or breastfeeding, and common side effects include nausea, constipation and diarrhea, according to the Mayo Clinic, which notes weight-loss drugs “can be expensive and aren’t always paid for by insurance coverage.”

“Payers tend not to cover weight loss medications. This goes for commercial insurers as well as Medicare and Medicaid. In fact, Medicare is prohibited by law from covering them. Many insurers and employers who sponsor health coverage consider weight loss a cosmetic need rather than a medical one,” the Obesity Medicine Association said in a December 2023 social media post. “Whether any given payer covers these medications can vary from one plan to another. Some plans, from some payers, cover certain weight loss medications. Some will do so with prior authorization. Others will not cover them at all. A patient will need to check the details of their own plan.”

Synchrony, a financial services company based in Stamford, Connecticut, covers prescription weight-loss drugs under its pharmacy program with CVS Pharmacy, subject to prior authorization, says Synchrony vice president of benefits Erika Scrugham. “Synchrony also has a weight-management bundle to ensure all new weight-loss drugs that come to market are automatically targeted for utilization. Once a member meets the requirements, the coverage will be subject to deductible and applicable plan cost-share,” she explains.

Randy Vogenberg, principal at the Institute for Integrated Healthcare, says prescription drugs in general, including those that address obesity, “can be covered under a medical or pharmacy benefit. Holistic health should be an integrated-benefit mindset to singularly address all drugs (medications, therapies), whether under medical or pharmacy benefit.”

Sherree Geyer Contributing Writer Read More

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