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Prevalence of New-Generation Obesity Medication Coverage - US Heat Map Value Definitions:

Covered

The health insurance plan in which an individual is enrolled includes at least one new-generation obesity medication as a covered drug for those enrollees who meet the medical necessity requirements or conditions for coverage established by the plan

Total Visual Lives Note

The total number of people in plans reviewed to determine coverage or exclusion of new-generation obesity medication (as available in AXIACI)

Overall Coverage of New-Generation Obesity Medication Value Definitions:

Covered

The health insurance plan in which an individual is enrolled includes at least one new-generation obesity medication as a covered drug for those enrollees who meet the medical necessity requirements or conditions for coverage established by the plan

Excluded

The health insurance plan in which an individual is enrolled excludes coverage for all new-generation obesity drugs

Indicators of exclusion include specific exclusion language in plan documents or on website of payer, and/or excluded or not present on the plan formulary.

Total Visual Lives Note

The total number of people in plans reviewed to determine coverage or exclusion of obesity (as available in AXIACI)

State Comparison Overall Coverage of New-Generation Obesity Medication Value Definitions:

Covered

The health insurance plan in which an individual is enrolled includes at least one new-generation obesity medication as a covered drug for those enrollees who meet the medical necessity requirements or conditions for coverage established by the plan

Excluded

The health insurance plan in which an individual is enrolled excludes coverage for all new-generation obesity drugs

Indicators of exclusion include specific exclusion language in plan documents or on website of payer, and/or excluded or not present on the plan formulary.

Total Visual Lives Note

The total number of people in plans reviewed to determine coverage or exclusion of obesity (as available in AXIACI)

Overall Coverage of Any Obesity Medication Value Definitions:

Covered

The health insurance plan in which an individual is enrolled includes at least one obesity medication (of any kind) as a covered drug for those enrollees who meet the medical necessity requirements or conditions for coverage established by the plan

Excluded

The health insurance plan in which an individual is enrolled excludes coverage for any kind of obesity medication

Indicators of exclusion include specific exclusion language in plan documents or on website of payer, and/or excluded or not present on the plan formulary.

Total Visual Lives Note

The total number of people in plans reviewed to determine coverage or exclusion of obesity medication (as available in AXIACI)

Prevalence of Any Obesity Medication Coverage – US Heat Map Value Definitions:

Covered

The health insurance plan in which an individual is enrolled includes at least one obesity medication (of any kind) as a covered drug for those enrollees who meet the medical necessity requirements or conditions for coverage established by the plan

Total Visual Lives Note

The total number of people in plans reviewed to determine coverage or exclusion of obesity medication (as available in AXIACI)

Coverage Criteria - Level of Overweight or Obesity Value Definitions:

The new generation of obesity drugs are approved by the FDA with a label that includes the level of overweight or obesity of patients for whom it is designed. Health insurance plans may adopt coverage criteria that reflects the label, or they may adopt criteria that is more stringent than the label, based on their review of the evidence, which may include considerations such as a drug’s value or cost and how it compares to other treatments.

Label

The health insurance plan in which the individual is enrolled uses the definition of BMI for overweight and obesity that is contained in the label for the drug

Higher

The health insurance plan in which the individual is enrolled uses a BMI level that is higher than what is included in the label for the drug

Only With Comorbidity

The health insurance plan in which the individual is enrolled does not cover obesity medication solely for the treatment of obesity. In other words, the patient must have another serious condition that is caused or exacerbated by overweight or obesity (a comorbid condition).



Under Medicare, obesity drugs for the treatment of obesity are not allowed to be covered. However, Wegovy has been approved by the FDA to reduce the risk of serious heart conditions in adults with obesity and overweight. Medicare plans can now cover Wegovy for those with serious heart conditions who are also overweight or obese because it is not for the sole purpose of treating obesity.

Total Visual Lives Note

Visual is based on the total number of people in plans with coverage of new-generation obesity medication (as available in AXIACI)

Coverage Criteria - Documentation of Failed Weight Loss Attempt Value Definitions:

Yes

Requires documentation of previous weight loss attempts

No

Does not include a requirement for documentation of previous weight loss attempts

Yes - 6 months within previous 12 months

Requires documentation of participation in a structured, comprehensive weight loss program that includes some combination of behavioral modification, increased physical activity and reduced calorie diet for at least 6 of the 12 months immediately prior to the request for coverage and that the individual did not achieve adequate weight loss (generally defined as equal to one pound per week).

Yes - Within 12 months

Requires documentation of participation in a structured, comprehensive weight loss program that includes some combination of behavioral modification, increased physical activity and reduced calorie diet for a specified amount of time within the 12 months immediately prior to the request for coverage and that the individual did not achieve adequate weight loss (generally defined as equal to one pound per week).

Yes - 3 months prior

Requires documentation of participation in a structured, comprehensive weight loss program that includes some combination of behavioral modification, increased physical activity and reduced calorie diet for at least 3 months immediately prior to the request for coverage and that the individual did not achieve adequate weight loss (generally defined as equal to one pound per week).

Yes - 6 months prior

Requires documentation of participation in a structured, comprehensive weight loss program that includes some combination of behavioral modification, increased physical activity and reduced calorie diet for at least 6 months immediately prior to the request for coverage and that the individual did not achieve adequate weight loss (generally defined as equal to one pound per week).

Total Visual Lives Note

Visual is based on the total number of people in plans with coverage of new-generation obesity drugs (as available in AXIACI)

Renewal Conditions: Proof of Diet/Exercise Adherence Value Definitions:

Yes

The health insurance plan in which an individual is enrolled requires documentation of adherence to a structured diet and exercise regime (while taking an obesity medication) before the obesity medication can be renewed

No

The health insurance plan in which an individual is enrolled does not require documentation of adherence to a structured diet and exercise regime (while taking an obesity medication) before the obesity medication can be renewed

Total Visual Lives Note

Visual is based on the total number of people in plans with coverage of new-generation obesity drugs (as available in AXIACI)

Renewal Conditions: Weight Loss Value Definitions:

No

There is no stated requirement for a threshold weight loss before the obesity medication prescription will be renewed

Yes - 4%

Patient must have documentation of at least 4% weight loss the obesity medication prescription will be renewed

Yes - 5% or greater

Patient must have documentation of at least 5% weight loss the obesity medication prescription will be renewed

Total Visual Lives Note

Visual is based on the total number of people in plans with coverage of new-generation obesity drugs (as available in AXIACI)

Prevalence of Bariatric Surgery Coverage - US Heat Map Value Definitions:

Covered

The health insurance plan in which an individual is enrolled includes bariatric surgery as a covered service for those enrollees who meet the medical necessity requirements or conditions for coverage established by the plan

Total Visual Lives Note

The total number of people in plans reviewed to determine coverage of bariatric services (as available in AXIACI)

Overall Coverage of Bariatric Surgery Value Definitions:

Covered

The health insurance plan in which an individual is enrolled includes bariatric surgery for those enrollees who meet the medical necessity requirements or conditions for coverage established by the plan

Excluded

The health insurance plan in which an individual is enrolled excludes coverage for bariatric surgery

Total Visual Lives Note

The total number of people in plans reviewed to determine coverage or exclusion of bariatric surgery (as available in AXIACI)

Coverage Criteria - Level of Overweight or Obesity Value Definitions:

The ASMBS (American Society for Metabolic and Bariatric Surgery) updated its evidence-based guidelines for bariatric surgery in 2022. We have measured plan requirements against the new guidelines for BMI levels: The ASMBS/IFSO Guidelines now recommend metabolic and bariatric surgery for individuals with a BMI of 35 or more “regardless of presence, absence, or severity of obesity-related conditions” and that it be considered for people with a BMI 30-34.9 and metabolic disease

Only With Comorbidity

The health insurance plan in which the individual is enrolled will only cover bariatric surgery if the patient has other medical conditions which are caused or exacerbated by obesity

Covered - More Restrictive

The health insurance plan in which the individual is enrolled uses coverage criteria more restrictive than the ASMBS 2022 guidelines

Covered - Meets 2022 ASMBS Criteria

The health insurance plan in which the individual is enrolled uses coverage criteria based on the ASMBS 2022 guidelines

Total Visual Lives Note

Visual is based on the total number of people in plans with coverage of bariatric surgery (as available in AXIACI)

Coverage Criteria - Documentation of Failed Weight Loss Attempt Value Definitions:

Yes

Documentation of failed diet and exercise attempts is required to qualify for coverage of bariatric surgery

No

Does not include a requirement of documentation of previous weight loss attempts

Total Visual Lives Note

The total number of people in plans reviewed that have bariatric surgery covered (as available in AXIACI)

Limitations on Correctional or Revisional Procedures Value Definitions:

Yes

The plan limits the number of revisional or correctional procedures

No

There are no arbitrary limits on follow-up procedures

Total Visual Lives Note

The total number of people in plans reviewed that have bariatric surgery covered (as available in AXIACI)

Coverage Criteria for Correctional or Revisional Procedures Value Definitions:

Yes

There is a restriction on follow-up procedures to bariatric surgery that excludes coverage if the patient does not follow post-surgical lifestyle guidelines

No

There is no stated restriction on follow-up procedures to bariatric surgery that excludes coverage if the patient does not follow post-surgical lifestyle guidelines

Total Visual Lives Note

The total number of people in plans reviewed that have bariatric surgery covered (as available in AXIACI)
Click to apply STATE BY STATE in the Visual Controller and select only the states in the current heatmap slider range
Click to apply STATE BY STATE in the Visual Controller and select only the states in the current heatmap slider range
Click to apply STATE BY STATE in the Visual Controller and select only the states in the current heatmap slider range
Click to apply STATE BY STATE in the Visual Controller and select only the states in the current heatmap slider range

NON-COMMERCIAL USER LICENSE (RWJF SPONSORED)

Get access to our non-commercial user license of AXIACI (Obesity Coverage Nexus), funded by the Robert Wood Johnson Foundation. This allows you to view the details behind the public platform release. Inside, you’ll find the actual data, extracted and derived for your needs.

If you’re looking for data outside of the Obesity Coverage Nexus’ scope, feel free to contact us about that as well. In addition to the non-commercial user license, we have the functionality to offer base data modules that can be as specific as needed.

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Leverage the varied levels of actionable information, insights and intel with solutions focused on coverage and access of products and/or services across markets, states, payors, employers, providers and PBMs.

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Obesity Medication

OVERVIEW

A new generation of medication to treat obesity has become available over the past 2 years. These medications have achieved significant results but are also high cost.

This page answers some of the most commonly asked questions:

  • How many people have plans that cover some or most of the cost of these drugs?
  • How does coverage vary based on where you live or how you obtain your health insurance?
  • Among those with coverage under their plan, how many have additional requirements that must be met in order to access the coverage?

OBESITY MEDICATION

The new-generation medication, often referred to as GLP-1s (glucagon-like peptide-1)

Recently approved by the FDA for the treatment of obesity are Wegovy (semaglutide), Zepbound (tirzepatide) and Saxenda (liraglutide). The data on this page primarily address the coverage and plan criteria for coverage of these medications.

COVERAGE AND COVERAGE CRITERIA

The visualizations on this page look at coverage from two perspectives:

  • At the plan level: whether an enrollee plan includes one or more of the drugs in its benefit package
  • At the enrollee/patient level: the criteria and policies adopted by the plan outlining the conditions that a patient must meet to obtain coverage for the obesity medication

Bariatric Surgery

OVERVIEW

Health insurance coverage of bariatric surgery has become more prevalent since the early 2000s and the sophistication and types of bariatric and metabolic surgery continues to expand and evolve. Some form of coverage is present in most health insurance plans. There is wide variation, however, in the requirements that must be met by providers for reimbursement and by patients to qualify.

Examples of requirements include: the procedure must take place in a Center of Excellence, patients must participate in a multidisciplinary pre-surgical program, patients with a history of substance abuse are excluded and only certain types of procedures are covered.

COVERAGE AND COVERAGE CRITERIA

The visualizations on this page look at coverage from two perspectives:

  • At the plan level: whether an enrollee plan includes coverage of bariatric and metabolic surgery
  • At the enrollee/patient level: the criteria and policies adopted by the plan outlining the conditions that a patient must meet to obtain coverage for both the initial procedure and any subsequent correctional and revisional procedures

Prevalence of New-Generation Obesity Medication Coverage - US Heat Map

The percentage of people with health insurance plans that include coverage of new-generation obesity medication varies significantly across states. The combination of factors at play includes how people are distributed across market segments, the dominant insurance carriers, and the self-insured employers in the state.

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Total Visual Lives:

Overall Coverage of New-Generation Obesity Medication

The percentage of people with health insurance plans that either cover at least one, or exclude all, new-generation obesity medication, across all selected states and all selected market segments.

Legend

Total Visual Lives:

State Comparison Overall Coverage of New-Generation Obesity Medication

Provides comparison of how many people in each state, across all selected market segments, are enrolled in plans which either include or exclude coverage of new-generation obesity drugs. By using the visual controller, you can make comparisons between states and market segments

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Total Visual Lives:

Overall Coverage of Any Obesity Medication

The percentage of people with health insurance plans that either cover at least one, or exclude all, of any obesity medication across all selected states and all selected market segments.

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Total Visual Lives:

Prevalence of Any Obesity Medication Coverage – US Heat Map

The percentage of people with health insurance plans that include coverage of any obesity medication varies significantly across states. The combination of factors at play includes how people are distributed across market segments, the dominant insurance carriers, and the self-insured employers in the state.

Legend

Total Visual Lives:

Coverage Criteria - Level of Overweight or Obesity

A common patient-level requirement for coverage of bariatric surgery is the level of overweight or obesity using BMI as the threshold criteria. Health insurance payers consider a broad range of evidence to develop the criteria for coverage of medication, such as a drug’s cost and how it compares to other treatments. This visual addresses how payers have defined the threshold of obesity and overweight necessary for a patient to qualify for coverage.

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Total Visual Lives:

Coverage Criteria - Documentation of Failed Weight Loss Attempt

A common patient-level requirement for coverage of a new-generation obesity drug is documentation of previous failed weight loss attempts. Payer criteria vary but generally include proof of participation in programs that address behavioral modification, reduced calorie diet, and/or increased physical activity, resulting in inadequate weight loss. This visual addresses the timing of the attempt in relation to the request for coverage.

Legend

Total Visual Lives:

Renewal Conditions: Proof of Diet/Exercise Adherence

The rate of payer requirements of documentation of adherence to a structured diet and exercise regime while taking any obesity medication.

Legend

Total Visual Lives:

Renewal Conditions: Weight Loss

Reflects the rate of payer requirements for a threshold weight loss as a condition of renewal of coverage for any obesity medication.

Legend

Total Visual Lives: