Without much fanfare, in December 2013, the American Medical Association House of Delegates (AMA) formally adopted its “Resolution 420.” In it, the AMA formally recognized obesity as a disease, unique unto itself; a disease that is often the precursor to many other highly prevalent disease states such as diabetes, hypertension, high cholesterol, and others. Resolution 420 was remarkable because it finally recognized obesity as a primary cause which, if effectively dealt with, could preempt the development of so many secondary harmful effects – effects which produce impaired clinical functioning, poor overall health, and which consume many financial and clinical resources when they emerge.
Unfortunately, despite the recent approval of several new prescription medications that are designed to produce and maintain weight loss and forgo the development of serious subsequent co-morbidities, most Pharmacy Benefit Plans continue to exclude weight loss medications from coverage in their Pharmacy Benefit Plans because of negative clinical experiences that occurred in the 1990s, and whose memory still lingers today.
These new medications, such as Qsymia and Belviq, have been approved by the FDA based on the availability of supporting data that establish clinical benefits that the older weight loss medications did not have; and, because of that, they ought to be considered by PBMs and Payers for coverage based on their own merits, not based on any remaining “class effect” bias that has survived for nearly twenty years.
If obesity truly is the first step in a chain of negative clinical consequences that lead to increasingly complicated and expensive secondary diseases, all tools – behavioral, diet, and pharmacological – ought to be made available to preempt those chronic co-morbidities, when appropriate under the right circumstances for a given patient under their physician’s close monitoring.
As weight loss moves to center-stage as a primary cause, all PBMs and Payers should reconsider the current coverage status of the new prescription weight loss medications based on their potential to add new tools to the pursuit of the health and wellness of their beneficiaries and their dependents.