As highlighted by this article, many obstacles exist when integrating new medications into employee health insurance plans.
The US healthcare system is set up in a way that allows drug companies to set high prices for their products. Insurers can negotiate some of these prices down, but they are also incentivized to restrict coverage to keep costs low.
Insurance companies’ coverage decisions are worsening existing health disparities by making it more difficult for people from low-income communities and racial and ethnic minority groups to access weight loss medications.
Since the American workforce is more mobile, with an average tenure of only four years, employer plans typically only cover a patient for a few years, so they are focused on short-term savings rather than long-term benefits.
This situation is unique to the US.
Other developed countries with high obesity rates also face the challenge of paying for weight-loss treatments, but they don’t have the same cost pressures as the US.
For example, in the UK, one month’s supply of Wegovy costs about $88, or if it becomes available on the NHS, it would be either free or cost the standard prescription fee of about $10 per order.
In comparison, the same medicine has a list price of $1,349 in the US.
Employers, insurers, and healthcare providers need to collaborate to overcome these barriers.
Employers have three options when it comes to covering anti-obesity drugs:
1. Excluding coverage is the most straightforward option.
It will save employers money on drug costs, but it may also lead to some employees seeking off-label prescriptions for the versions of these medications approved for diabetes treatment. This could widen health inequalities, as higher-wage and more highly educated employees are more likely to be able to afford off-label prescriptions.
Employers might also face a disadvantage in attracting and retaining employees if rival companies provide benefits that include coverage for anti-obesity medications.
2. Covering with restrictions can be more cost-effective than excluding coverage, while ensuring that employees who are most likely to benefit from anti-obesity drugs have access to them.
One way to do this is to set a higher BMI threshold for eligibility for coverage. This would mean that only employees with the most severe obesity would be eligible for coverage, lowering the overall medication cost.
However, some employees with BMIs below the threshold may seek off-label prescriptions for the versions of these medications approved for diabetes treatment.
3. Providing permissive coverage is the most expensive option but also the most satisfactory for employees. This implies that employers would provide coverage for anti-obesity medications whenever a physician states it is a medical necessity with minimal review.
This would ensure that all employees who could benefit from anti-obesity drugs have access, but it would also come at a higher cost. Employers may also gain a competitive advantage in hiring if they offer permissive coverage for anti-obesity drugs.