Obesity rates have been steadily climbing, with the CDC reporting a significant increase from 30.5% between 1999 and 2000 to 41.9% between 2017 and March 2020. This rise in obesity has led to a surge in related health conditions such as heart disease, stroke, type 2 diabetes, and certain cancers, which are among the leading causes of preventable death. In response to this growing health crisis, Optum Rx has launched Optum Rx Weight Engage, a comprehensive weight management and wellness support program designed to support employers, health plans, and consumers, while also providing better health outcomes and managing drug spending.
Understanding Optum Rx Weight Engage
Optum Rx Weight Engage is a multifaceted program designed to provide a comprehensive approach to weight management. The program is structured to support consumers in navigating their specific benefit coverage, connecting them with a specialized provider network, and offering coaching and lifestyle programs. Clients have the flexibility to configure elements that best fit their and their consumers’ needs.
Dr. Patrick Conway, CEO of Optum Rx, stated that Optum Rx Weight Engage offers clinically appropriate programs that support wellness and better health for consumers and solutions to help clients manage drug spending.
Key Components of the Program
Navigation of Benefit Coverage: The program assists consumers in understanding and navigating their specific health plan benefits related to weight management.
Specialized Provider Network: Consumers gain access to a network of healthcare professionals specializing in obesity management.
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Coaching and Lifestyle Programs: The program integrates coaching and lifestyle programs to support consumers in achieving their weight loss goals.
Tailored Program Development: The program begins with a review of the client's goals to build a tailored program that will deploy clinical solutions as well as patient monitoring and motivation and support tools.
Wellness Support Component: The program enrolls members in a wellness support component in which a health coach assists with reaching weight loss goals.
Access to Weight Loss Medications
Optum Rx standard formularies include weight loss drugs like Wegovy (semaglutide) and Saxenda (liraglutide). The pharmacy benefit manager (PBM) is also evaluating Zepbound (tirzepatide) for inclusion in its formularies. These medications activate receptors of hormones such as glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), which are secreted from the intestine to reduce appetite and food intake.
Formulary Updates
As of July 2024, Optum Rx’s standard formulary includes coverage of:
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- Saxenda, Wegovy, and Zepbound for weight loss
- Ozempic and Mounjaro for Type 2 diabetes
It's important to note that individual coverage is dependent on the specific plan.
Addressing the Cost of Insulin
In addition to weight management medications, Optum Rx is also addressing the cost of insulin. Beginning in January 2024, Optum Rx will shift eight insulin products, including all short- and rapid-acting insulins, to tier one, or “preferred” status, on standard formularies. Three manufacturers, including Eli Lilly, Novo Nordisk, and Sanofi, will have products added to tier one. As a result, 98% of all Optum Rx consumers will have access to insulin for $35 or less per month.
Optum's Financial Performance
Optum has demonstrated strong financial performance, with third-quarter revenues growing 22% to $56.7 billion. Operating earnings were $3.9 billion compared to $3.7 billion last year. Additionally, UnitedHealth Group's (UHG) $5.4 billion acquisition of home health company LHC Group formally closed in February.
The Importance of Medical Weight Loss
Medical weight loss (MWL) is a critical area of focus, given the complexities of obesity as a chronic disease. A series of educational activities are available through optumhealtheducation.com to meet the needs of dietitians, nurses, nurse practitioners, physicians, PAs, and other health care professionals interested in learning about MWL.
The series includes:
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Medical Weight Loss Overview: This activity provides an overview of obesity as a complex and chronic disease, reviews its classification, and examines the factors that cause weight loss to be so challenging to sustain.
Pharmacotherapy Principles and Considerations for Weight Management: This activity reviews the rationale, mechanisms of action, and indications for current FDA-approved anti-obesity pharmacotherapies, as well as explores medications that have weight-loss-promoting potential.
Supratentorial Matters Associated with Obesity: This activity focuses on the physiological processes that occur in obesity and cause fundamental changes in neurocircuitry that impact mental and physical health, sleep, aging, and the experience of pain.
Coverage Criteria and Potential Denials
For individuals with a private health insurance plan, access to GLP-1 medications for weight loss or the treatment of type 2 diabetes may be available. Generally, Optum Rx will include coverage of weight loss GLP-1s with a BMI of 30 or higher OR with a BMI of 27 or higher AND a diagnosis of one or more weight-related conditions such as hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, or cardiovascular disease. They’ll also offer coverage of Ozempic or Mounjaro with a confirmed diagnosis of type 2 diabetes.
Understanding Coverage Restrictions
While Optum Rx offers coverage of these medications, individual coverage options depend on the specific insurance plan. Many plans have restrictions in place for approval, such as:
- Step therapy
- A weight management program policy
- A full weight loss exclusion
Medicare Coverage
Medicare through Optum Rx does not include coverage for weight loss meds, though it does include coverage of Ozempic and Mounjaro for the treatment of Type 2 diabetes.
Appealing a Denial
If a request for coverage of Zepbound, Ozempic, or other GLP-1/GIP medication is denied by Optum Rx, the first step is to check the denial reason provided in a letter from the insurance company. Common denial reasons include medical necessity, step therapy, requirements for previous participation in a weight loss program, failure to prove lifestyle modification, or a weight loss plan exclusion.
Appealing a coverage denial is always recommended. Honest Care provides free well-crafted appeal letters to assist in this process.
Honest Care's Role in Advocating for Patients
Honest Care assists patients in fighting insurance coverage denials so they can get access to the medications and treatments they deserve. They specialize in insurance coverage denials for Ozempic, Mounjaro, Wegovy, and Zepbound.
How Honest Care Helps
Online Denial Assessment: Completing an online assessment gathers all necessary appeal evidence for the insurance company.
Case Evaluation & Appeal Strategy: A dedicated appeal specialist reviews the assessment and insurance denial to identify the best appeal arguments for coverage.
Appeal Letter & Supporting Documents: An appeal writer composes a professional appeal letter addressing the denial reason and detailing the case for coverage.
Specialist Consultation & Support: A dedicated appeal specialist is available to answer questions and make updates to the appeal, if required.
The Importance of Appealing
Appealing coverage denials is crucial, as denials are often issued by mistake. A computer almost always makes the initial decision to deny medication coverage, resulting in denials that don’t consider personal health situations. When an appeal is submitted, the information is reviewed by a real person.