Employers are paying for obesity ALREADY - either directly or indirectly.
The edits used to restrict GLP-1 usage to “diabetics only” are far from effective if trying to prevent off- label use. Ineffective automated step edits in place with some PBMs require 30 days of a metformin “trial” prior to approval of Ozempic, as an example. There is no requirement for a member to actually take / swallow the medication and no bloodwork is required to see if the metformin “worked”. FYI that a one month metformin trial is far too short for a type 2 diabetic to see and feel results.
It’s going to be important to monitor and audit current plan metrics to measure how well current restrictions are working and adjust and adapt as necessary.
A holistic approach is required, not just medicine-based.
Best in class approach is likely a point solution that is holistic and end-to-end, providing for medications only after other traditional and behavioral treatments have been tried.
Consider exclusion of AOMS (anti-obesity medications) from health plan coverage and rely on a carved out point solution that is fully integrated with behavioral, movement, & nutritional counseling and patient accountability.
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