Many Insurers Don't Cover Weight-Loss Drugs
Saturday, March 14, 2015 11:37 AM

From the “What goes around, comes around” department comes this lament from the medical/pharmaceutical industry: In December, the FDA approved a new anti-obesity drug, the fourth prescription drug the agency has given the green light to fight obesity since 2012. But even though two-thirds of adults are overweight or obese there's a good chance their insurer won't cover anti-obesity drugs.

The health benefits of using anti-obesity drugs to lose weight may not be immediately apparent. "Most health plans will cover things that have an immediate impact in that plan year," says Dr. Steve Miller, the chief medical officer at Express Scripts, which manages the prescription drug benefits for thousands of companies.

Miller estimates that about a third of companies don't cover anti-obesity drugs at all, a third cover all FDA-approved weight-loss drugs, and a third cover approved drugs, but with restrictions to limit their use. The Medicare prescription drug program specifically excludes coverage of anti-obesity drugs.

As the link between obesity and increased risk for type 2 diabetes, heart disease, cancer, and other serious medical problems has become clearer, prescription drugs are seen as an opportunity. Obesity accounts for 21% of annual medical costs in the U.S. or $190 billion, according to a 2012 study published in the Journal of Health Economics.  In 2013, the American Medical Association officially recognized obesity as a disease.

Many people who take an anti-obesity drug will remain on it for the rest of their lives. That gives insurers pause, says Miller.  The potential cost to insurers could be enormous, he says.

In 2012, the U.S Preventive Services Task Force, a nonpartisan group of medical experts who make recommendations about preventive care, declined to recommend prescription drugs for weight loss, noting a lack of long-term safety data, among other things. The task force did recommend obesity screening for all adults and children over age 6, however, and recommended patients be referred to intensive diet and behavioral modification interventions.

Under the health law, nearly all health plans must cover preventive care recommended by the task force without cost sharing by patients. Implementation of the obesity screening and counseling recommendations remains a work in progress, say experts.  "Coverage has to happen in order for the obesity problem to be taken care of.  Insurance companies need to realize it's not a matter of willpower, it's a disease."