Obesity Management Framework
We created this framework to enable employers to consider how comprehensive obesity care, including anti-obesity medications (AOMs), impacts their business.
Select your health plan to learn more:
Why we created this framework
Obesity has been classified as a disease by the American Medical Association since 2013, impacting approximately 42% of the U.S. population according to the Centers for Disease Control. With more than 200 diseases associated with the condition, the demand for weight management solutions has never been higher. Many believe anti-obesity medications (AOMs) have the potential to meet this growing need as part of comprehensive obesity care. Because of the surging demand, increasingly effective treatments, potential cost impact and the evolving realization that obesity is a chronic disease with numerous negative health consequences, payers require guidance on how to implement and manage this complex disease.
How to use this framework
The framework will enable employers to have important discussions with their health plan, pharmacy benefit manager (PBM) and third-party vendors about what coverage is in place today and what they can do to implement, improve or manage coverage going forward. The framework is organized to allow self-insured and fully Insured employers to evaluate criteria based on their situation.
Select Examples of Weight-Related Comorbidities
Healthcare Utilization and Pharmacy Costs for Obesity-Related Comorbidities Exert Pressure on the US Healthcare Budget
Important Update
An additional strategic market segment dynamic is that Medicare now allows coverage of Wegovy (one of the FDA-approved AOMs) to reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and either obesity or overweight.
Medicare’s decision to cover this GLP-1 AOM for those who are at high cardiovascular risk will likely result in commercial plans expanding coverage as well. This is a marketplace driver that is important to monitor actively as AOMs receive additional indications beyond their currently approved labels. Furthermore, this is the first AOM to be covered by Medicare.
Obesity Management Framework Contributors
(In alphabetical order)
AJ Ally, RPH, MBA, Equity Principal, Milliman
Jeff Garbe, RPH, Sr. Pharmacy Management Consultant, Milliman
Mark Gruenhaupt, RPH, MBA, Sr. Pharmacy Management Consultant, Milliman
Peter Heinen, FSA, Consulting Actuary, Milliman
Max Karpman, PharmD, MBA, Strategic Pharmacy Consultant, Valued Pharmacy Services
Katherine Saunders, MD, Co-Founder and Executive Vice President, Intellihealth
Julia Shelton, Pharm D, Sr. Pharmacy Management Consultant, Milliman