Obesity and related health issues are a growing concern. Meritain Health offers resources and support for members seeking information on their benefits, including weight loss medication coverage.
Accessing Information and Support
Meritain Health encourages members to utilize their personalized member site and mobile app for round-the-clock access to information, tools, and resources. For further assistance, members can contact Meritain Health directly.
Appealing Coverage Denials
Meritain Health provides a multi-level appeal process for members whose claims are denied.
- Level 1 - Internal Appeal: Members can request a review of the initial denial of coverage.
- Level 3 - External Appeal: After exhausting the internal appeal process, members can request an external review of the final adverse determination. This requires completing specific forms and submitting them with a formal written appeal from the provider to the Meritain Health Appeals Department.
General Considerations for Weight Loss Medication Coverage
It is essential to understand that many Aetna benefit plans (Meritain Health is an Aetna company) specifically exclude services and supplies for obesity treatment, diet, or weight control. Under these plans, claims for weight reduction medications and physician supervision of weight reduction programs will be denied.
Medical Necessity Criteria
The medical necessity criteria mentioned below do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control.
Read also: Benefits of couples massage detailed
When weight reduction medications are covered, they are typically considered an adjunct to caloric restriction, exercise, and behavioral modification when these measures alone have not resulted in adequate weight loss. Weight loss due to medication is generally temporary, and the potential for physical dependence and addiction is high. However, individuals who cannot maintain weight loss through behavioral weight loss therapy and are at risk of medical complications of obesity may be an exception, where the risk of continued obesity outweighs the risk of adverse effects from medication.
It's important to note that initial responders to weight loss drugs tend to continue to respond, while initial non-responders are less likely to respond even with an increase in dosage. If a person does not lose 2 kg (4.4 lbs) in the first four weeks after initiating therapy, the likelihood of long-term response is very low.
Weight Reduction Counseling
Aetna considers up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period as medically necessary for weight reduction counseling in adults who are obese (as defined by BMI greater than or equal to 30 kg/m2).
Specific Weight Loss Medications
Several weight loss medications have been approved for use in specific circumstances. However, coverage varies depending on the specific plan.
- Didrex (benzphetamine hydrochloride): This is an anorectic agent indicated for short-term use in managing exogenous obesity in patients with a BMI of 30 kg/m2 or higher who have not responded to diet and/or exercise alone. It is contraindicated in patients with advanced arteriosclerosis, cardiovascular disease, moderate to severe hypertension, hyperthyroidism, hypersensitivity to sympathomimetic amines, and glaucoma. It should not be given to patients who are in an agitated state or who have a history of drug abuse. Didrex is also contraindicated in pregnant women and should not be used in combination with other anorectic agents.
- Contrave (naltrexone and bupropion): This combination medication is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).
- Xenical (orlistat): Indicated for obesity management including weight loss and weight maintenance when used in conjunction with a reduced‐calorie diet. It is also indicated to reduce the risk for weight regain after prior weight loss. Recommended dosage of Xenical is one 120-mg capsule three times a day with each main meal containing fat (during or up to 1 hour after the meal). Supplementation with fat‐soluble vitamins (A, D, E, K) and beta carotene is recommended in some patients as these may not be adequately absorbed when given orlistat therapy. Xenical (orlistat) is contraindicated in persons with chronic malabsorption syndromes and cholestasis.
- Qsymia (phentermine and topiramate): This combination drug is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia. Qsymia is contraindicated in pregnancy, glaucoma, hyperthyroidism, hypersensitivity to sympathomimetic amines, and within 14 days of taking monoamine oxidase inhibitors.
- Belviq (lorcaserin): Was approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index (BMI) of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related co-morbid condition. The FDA’s February 13, 2020 Drug Safety Communication advised patients to stop taking Belviq and Belviq XR and talk to their health care professional about alternative weight-loss medications and weight management programs
- Saxenda (liraglutide): The FDA approved liraglutide [rDNA origin] injection (Saxenda), a once-daily injection of a glucagon-like peptide-1 (GLP-1) receptor agonist, for chronic weight management in adults with obesity (BMI ≥30 kg/m2) or who are overweight (BMI ≥27 kg/m2) with comorbidities. Saxenda has a boxed warning stating that liraglutide causes thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice. It is unknown whether Saxenda causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumors has not been determined. Saxenda is contraindicated in patients with a personal or family history of MTC or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).
Important Considerations and Emerging Trends
Several factors influence the landscape of weight loss medications and their coverage.
Read also: How digestive health affects weight loss
- GLP-1 Receptor Agonists: GLP-1s are effective in assisting with decreasing appetite and slowing digestion, both helpful in weight loss. This is in addition to how they work for patients with diabetes, by increasing insulin production and lowering blood sugar levels.
- Cost: The high cost of GLP-1 drugs remains a significant hurdle for many patients.
- Competition: New GLP-1s are continually entering the pharmaceutical pipeline.
- Long-Term Safety and Effectiveness: GLP-1s have shown impressive short-term results. However, their long-term effects remain unclear. More data is needed to understand potential side effects and their lasting impact on weight and metabolic health.
- Dosage Forms: With the exception of one FDA-approved oral medication, most GLP-1s exist as injectables. It’s expected more oral tablet options may become available in the future, including those for weight loss. Currently, there’s no significant cost savings associated with oral options.
Meritain Health's Approach to GLP-1 Coverage
Employer approaches to covering GLP-1s aren’t one-size-fits-all. At Meritain Health®, we offer a flexible range of cost management and utilization strategies. We can walk you through approaches to cover diabetes only or a combination of diabetes and obesity. There’s a lot to consider around GLP-1s. It’s important to understand other factors too, like your industry and individual employee population. We’re here to help. Through thoughtful recommendations, it’s our role to guide plan sponsors toward elections that make the most sense for all participants. This can even be enhanced with general wellness and behavioral solutions aimed at addressing conditions in a holistic way.
Additional Therapies and Considerations
Besides pharmaceutical approaches, several other therapies and considerations are relevant in weight management.
- Medicinal Plants and Natural Treatments: Medicinal plants and natural treatments are becoming more and more popular. Different mechanisms for the anti-diabetic effect of plants have been proposed: increased release of insulin, reduction of intestinal glucose absorption, as well as enhancement of glycogen synthesis. The scientific evidences for most of these plants are still incomplete.
- Capsaicinoids: Capsaicinoids are a group of chemicals naturally occurring in chili peppers with bioactive properties that may help to support weight management. Data analysis showed that capsaicinoid ingestion prior to a meal reduced ad libitum energy intake by 309.9kJ (74.0kcal) during the meal (p < 0.001).
- Very-Low-Energy Diets (VLED): Evidence from the literature supports the safe use of very-low-energy diets (VLED) for up to 3 months in supervised conditions for patients who fail to meet a target weight loss using a standard low-fat, reduced-energy approach.
- Indirect Calorimetry: Using indirect calorimetry to set energy goals is another approach. Investigators reported that treatment participants lost significantly more weight than usual care participants (p ≤ 0.05).
- Whole Body DEXA and Bio-impedance: Available evidence does not support the use of whole body DEXA for managing obesity. There is currently no established role for whole body bio-impedance for weight reduction or other indications.
Read also: Weight Loss Meds & BCBS