November 2023 Market Edge News for All Segments

Changes to obesity management policy and new options for self‑funded groups

People who are overweight or obese are at an increased risk of many serious diseases and health Conditions. AmeriHealth offers comprehensive coverage for obesity management. Members may have access to coverage for weight loss medications, bariatric surgery, and preventive care services (e.g., obesity screening, behavioral counseling, and nutritional counseling) depending on their benefit design.

The health care system has experienced a dramatic increase in the utilization of weight loss medications. With several costly glucagon-like peptide-1 (GLP-1) branded products on the market, promoting appropriate use is key to managing prescription costs. To ensure clinically appropriate use of these medications and to make sure our members have long-term, sustainable success with weight loss medications, AmeriHealth will be updating its coverage policy for obesity management for fully insured members, and offering new options for self-funded groups. The goal of this update and the new program options is to support members while maintaining affordable health care for all.

Fully insured customers

Effective January 1, 2024, coverage for weight loss medications will be updated for AmeriHealth customers who currently have elected pharmacy coverage for obesity management. Please note, this does not apply to ACA, Fixed Funding, or Large Group Commercial. To be eligible for weight loss drug coverage, members must now:

  • Have a body mass index (BMI) measurement over 30kg/m2 or a BMI over 27kg/m2 with at least one obesity-related comorbidity, AND
  • Complete a lifestyle management program for six months before weight loss medications are covered. A physician will need to attest (or confirm) that the member completed six months of a lifestyle management program with continued participation thereafter, AND
  • Members who are starting weight loss drug therapy medications for the first time will be asked to try Qsymia or Contrave as appropriate. Applicable cost-sharing will apply for all weight loss medications, AND
  • Members must take the weight loss medications as prescribed, AND
  • A reauthorization is required every 6 months.

Member outreach

Letters will be sent to affected members who are currently taking weight loss medications to outline the changes to their prior authorization requirements.

Sample member letter

AmeriHealth Administrators customers

Providing access to weight loss products in prescription benefits provides additional health-related advantages to members but is also quite costly to employers. Beginning in 2024, we are pleased to provide access to the branded GLP-1 products* for weight management, Wegovy® and Saxenda®, while better controlling costs.

No action is required of clients that currently have the Standard Weight Loss rider in place, and if no action is taken, the current coverage and criteria for getting these medications will not change, except as noted below.

Select formulary 

Customers using the Select formulary are encouraged to consider upgrading to the new Highly Managed option. This option uses criteria that targets motivated obese and overweight individuals who have related health conditions. To be eligible for coverage of branded GLP-1 products, members must:

  • Have a BMI ≥ 30 OR BMI ≥ 27 with obesity related comorbidity, AND
  • Have completed a prior trial of, or demonstrated an inability to use, a non-GLP-1 medication indicated for treatment of obesity, AND
  • Have a previous history of weight loss management program participation, AND
  • Use the GLP-1 branded product as part of a weight loss program in conjunction with caloric restriction and exercise

The Highly Managed option can be activated at any time, and does not need to be tied to a group’s anniversary date. The lead time for a group to go live is typically 45 days. However, clients deciding by December 15, 2023, will be able to go live on January 1, 2024.

Please be aware that with this new option, the GLP-1 medications for weight control will be excluded from rebates, and there is an administration fee.

Please note, for clients taking no action and deciding to continue with the Standard Weight Loss Rider currently in place, the current criteria for getting these medications will not change except that in January and February 2024, new starts for members will be subject to the Highly Managed policy. This temporary application is due to a coding limitation.

Premium formulary

Customers using the Premium formulary are encouraged to consider upgrading to the new Risk Managed option. This option uses more stringent criteria, similar to those which must be met for members to be eligible for bariatric surgery. To be eligible for coverage of branded GLP-1 products, members must:

  • Have a BMI ≥ 35 with a high-risk cardiovascular related comorbidity, AND
  • Have completed a prior trial of, or demonstrated an inability to use, a non-GLP-1 medication indicated for treatment of obesity, AND
  • Use the GLP-1 branded product as part of a weight loss program in conjunction with caloric restriction and exercise

The Risk Managed option can be activated at any time and does not need to be tied to a group’s anniversary date. The lead time for a group to go live is typically 45 days.

Please be aware that with this new option, the GLP-1 medications for weight control will be excluded from rebates, and there is an administration fee.

Helping members live healthier lives

AmeriHealth is focused on helping members address obesity and supporting healthy lifestyles. Comprehensive lifestyle changes, including diet, exercise, and behavioral modifications, are the cornerstone of healthy living and should be a part of every obesity management journey.

* GLP-1 products covered subject to change