When the Food and Drug Administration approved Saxenda in December, it became the fourth anti-obesity prescription medication the agency has given the green light to since 2012. But even though two-thirds of adults are overweight or obese — and many may need help sticking to new year’s weight-loss resolutions — there’s a good chance their insurer won’t cover Saxenda or other anti-obesity drugs.
The benefits of using anti-obesity drugs to lose weight — improvements in blood sugar and risk factors for heart disease, among other things — may not be immediate. “For things that are preventive in the long term, it makes plan sponsors think about their strategy,” says Steve Miller, the chief medical officer at Express Scripts, which manages the prescription drug benefits for thousands of companies. Companies with high turnover, for example, are less likely to cover the drugs, he says.
“Most health plans will cover things that have an immediate impact in that plan year,” Miller says.
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 them with restrictions to limit their use. The Medicare prescription drug program specifically excludes coverage of anti-obesity drugs.
Part of the reluctance to cover weight-loss drugs stems from serious safety problems with diet drugs in the past, including the withdrawal in 1997 of fenfluramine, part of the fen-phen diet drug combination that was found to damage heart valves.
Back then, weight-loss drugs were often dismissed as cosmetic treatments. But 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 having a role in addressing the obesity epidemic. Obesity accounts for 21 percent of annual medical costs in the United States, or $190 billion, according to a 2012 study published in the Journal of Health Economics.
The newly approved drugs — Belviq, Qsymia, Contrave and Saxenda — work by suppressing appetite, among other things. Saxenda is administered via subcutaneous injection; the other three drugs come in pill form. They’re generally safer and have fewer side effects than similar older drugs. In conjunction with diet and exercise, people typically lose between 5 and 10 percent of their body weight, research shows — modest weight loss but sufficient to meaningfully improve health.
The drugs are generally recommended for people with a body mass index of 30 or higher, the threshold for obesity. They may also be appropriate for overweight people with BMIs in the high 20s if they have heart disease, diabetes or other conditions.
In 2013, the American Medical Association formally recognized obesity as a disease. Nevertheless, “people still assume that obesity is simply a matter of bad choices,” says Ted Kyle, advocacy adviser for the Obesity Society, a research and education organization. “At least half of the risk of obesity is inherited,” he says.
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.
Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade group, says the variability of insurer coverage of anti-obesity drugs “relates to issues of evidence of effectiveness and evidence of safety.”
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. But its analysis was based on older drugs: orlistat, which is sold over the counter as Alli or in prescription form as Xenical; and metformin, a diabetes drug that has not been approved for weight loss but is sometimes prescribed for that by doctors.
The task force did recommend obesity screening for all adults and children over age 6, however, and recommended that some 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.
Caroline Apovian, director of the Nutrition and Weight Management Research Center at Boston University, says many of the patients she treats can’t afford to pay up to $200 a month out of pocket for anti-obesity drugs.
“Coverage has to happen in order for the obesity problem to be taken care of,” says Apovian. “Insurance companies need to realize it’s not a matter of willpower, it’s a disease.”
This column is produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente. E-mail: firstname.lastname@example.org.