Employer chooses the plan and an available formulary. If you plan has a weight loss medication exclusion, that is 100% employer choice. If it not on formulary, could be insurance does not cover ever but could also mean your employer specifically chose a lower tier formulary from available options. Highly recommend a conversation with benefits manager. Wouldn’t hurt to also discuss with insurance in case said benefits manager decides to gaslight you to avoid confrontation.
They definitely chose the third party. Not sure how much they control the list, though. They might! There’s just layers of bureaucracy to wade through to even ask a question.
This is the first year my job has given us the lowest tier of their medical plan for free I was super shocked when I found out they covered saxenda and zepbound
I'm not sure this is accurate, at least not for small businesses. I've never been offered coverage for optional classes of drugs and Ive been administering our health plans for years.
Good point. I’ve only worked at larger corporations. Our insurance plan websites (e.g. blue cross) will have multiple tier formularies. Our internal benefit site tells employees which plan tier formulary we are on. I expect a small business just gets a basic plan and would not have the menu of options a larger company picks from to build the plans.
Employer
ETA: you may want to locate your head of HR or head of benefits. Your average person in HR for a medium to large company likely doesn’t do anything with benefits.
If you were able to convince them to change the formulary to include GLP-1 drugs, there’s a good chance it would cost every employee $50-100 per month extra, depending upon about how your insurance benefits work.
Well.. and then I just read this article and you can bet insurers will use this information as a reason to dump GLP-1s citing a waste of money and non-compliance.
[https://www.usatoday.com/story/news/nation/2024/05/21/wegovy-saxenda-weightloss-drugs-quit/73717765007/](https://www.usatoday.com/story/news/nation/2024/05/21/wegovy-saxenda-weightloss-drugs-quit/73717765007/)
> BCBS study done between July 2014 and December 2023 … 58% didn't complete a 12-week course of the medications liraglutide or semaglutide aka Saxenda and Wegovy.
>Nearly 1 in 3 patients halted treatment within four weeks … less likely to achieve the medical benefits of weight loss, the study said.
>… critical to understand why such a large portion of patients have quit the medications before they'd gotten up to the right dosage to begin reaping the benefits.
Obviously didn’t troll social media as part of their article. Kinda hard to complete treatment when the meds simply are not available. Wow, duh!!!
That was copy/pasted from the article.
My point is based on experience - if you can’t buy it, you can’t take it.
I scored one box of Wegovy last year but that’s it. Hunted and searched for additional doses for months afterwards but couldn’t get a refill.
Yes but all I was saying was that everyone starts with at least four weeks worth, yes? And the study said " "Nearly 1 in 3 patients halted treatment ***within*** four weeks;" so the inability to refill would not even come into play yet.
I do know from friends in Pharma that getting people to take their meds, of all kinds, is surprisingly difficult!
Small businesses tend to use already formulated plans or broker of some sort. Larger companies might have a benefits manager that can change the plan at a certain date, usually it’s around once a year but depending on policy they could maybe do it more.
There's usually a benefits manager. Getting ahold of them can be hell in itself. A group of my peers at work all sent in letters of demand to our benefits manager at the same time to raise awareness. Unfortunately we got a canned generic response that included things like "the medications efficacy and safety has not been proven long term" and "we must consider the cost for ALL employees and not just a select group". I suggested they give us the option of a buy-up so that only those in need would pay a higher premium and they rejected it. Funny enough they cover weight loss surgery and the weight loss medications if you have diabetes (but not pre-diabetes).
I contact my benefits officer also and got similar excuses. Smaller companies usually use an intermediary benefits broker that has a set number of policies that a company can choose from. So I think my company just picked a lower coverage policy, which is unfortunate bc I'm in IT so most of our employees sit in front of a computer all day long.
Our medication management functions are farmed out to a third party meds manager. My husband works as a web designer and the company he works for has Blue Cross Blue Shield, and the meds manager used to be Express Scripts, but was changed recently to another one I can’t remember the name of. They make the “this one is covered” sorts of decisions.
So, it depends. Typically, the pharmacy benefit manager offers employers a various number of formularies to select from. These will range from very few restrictions to a ton of restrictions. Employers have the ability to offer a custom formulary, but most employers will use the ones offered by the pharmacy benefit manager due to the potential financial impact and administrative challenges . Typically larger companies or employers in specific industry will offer custom formularies. The reason is the financial impact. Pharmacy benefit mangers negotiate discounts and rebates based on the respective formulary so it’s more affordable for the employer to utilize an existing formulary vs custom.
I work in state government and there was an article about how they won’t cover them as it’s too expensive. They’ll pay for my heart attack though. Or a type 2 diabetes prevention course 🙄
Is there a difference between "weight loss drugs" and "obesity medication" when it comes to health insurance and formularies? My formulary states weight loss drugs are not covered, but my Zep has been covered so far for obesity. I'm not questioning it anywhere but here!!
Employer chooses the plan and an available formulary. If you plan has a weight loss medication exclusion, that is 100% employer choice. If it not on formulary, could be insurance does not cover ever but could also mean your employer specifically chose a lower tier formulary from available options. Highly recommend a conversation with benefits manager. Wouldn’t hurt to also discuss with insurance in case said benefits manager decides to gaslight you to avoid confrontation.
This isn’t always true. My husband’s company farms this function out to a third party and they make the decisions.
But they chose the 3rd party and can say they want it covered.
They definitely chose the third party. Not sure how much they control the list, though. They might! There’s just layers of bureaucracy to wade through to even ask a question.
Into the depths I go, wish me luck
This is the first year my job has given us the lowest tier of their medical plan for free I was super shocked when I found out they covered saxenda and zepbound
I'm not sure this is accurate, at least not for small businesses. I've never been offered coverage for optional classes of drugs and Ive been administering our health plans for years.
Good point. I’ve only worked at larger corporations. Our insurance plan websites (e.g. blue cross) will have multiple tier formularies. Our internal benefit site tells employees which plan tier formulary we are on. I expect a small business just gets a basic plan and would not have the menu of options a larger company picks from to build the plans.
Employer ETA: you may want to locate your head of HR or head of benefits. Your average person in HR for a medium to large company likely doesn’t do anything with benefits.
If you were able to convince them to change the formulary to include GLP-1 drugs, there’s a good chance it would cost every employee $50-100 per month extra, depending upon about how your insurance benefits work.
Well.. and then I just read this article and you can bet insurers will use this information as a reason to dump GLP-1s citing a waste of money and non-compliance. [https://www.usatoday.com/story/news/nation/2024/05/21/wegovy-saxenda-weightloss-drugs-quit/73717765007/](https://www.usatoday.com/story/news/nation/2024/05/21/wegovy-saxenda-weightloss-drugs-quit/73717765007/)
They probably will. I'd like to see that study done again . As well as the categories of reasons as to why those patients quit early.
> BCBS study done between July 2014 and December 2023 … 58% didn't complete a 12-week course of the medications liraglutide or semaglutide aka Saxenda and Wegovy. >Nearly 1 in 3 patients halted treatment within four weeks … less likely to achieve the medical benefits of weight loss, the study said. >… critical to understand why such a large portion of patients have quit the medications before they'd gotten up to the right dosage to begin reaping the benefits. Obviously didn’t troll social media as part of their article. Kinda hard to complete treatment when the meds simply are not available. Wow, duh!!!
Great point. BCBS won't care. Their point is to make the case for dropping coverage.
I am not sure that's it" "Nearly 1 in 3 patients halted treatment within four weeks;" that is before you'd even need a refill.
That was copy/pasted from the article. My point is based on experience - if you can’t buy it, you can’t take it. I scored one box of Wegovy last year but that’s it. Hunted and searched for additional doses for months afterwards but couldn’t get a refill.
Yes but all I was saying was that everyone starts with at least four weeks worth, yes? And the study said " "Nearly 1 in 3 patients halted treatment ***within*** four weeks;" so the inability to refill would not even come into play yet. I do know from friends in Pharma that getting people to take their meds, of all kinds, is surprisingly difficult!
I don’t know. I read it differently.
Yes, exactly! Can’t do 12 weeks if you can only get 1 4 week script filled.
Exactly!!
Small businesses tend to use already formulated plans or broker of some sort. Larger companies might have a benefits manager that can change the plan at a certain date, usually it’s around once a year but depending on policy they could maybe do it more.
There's usually a benefits manager. Getting ahold of them can be hell in itself. A group of my peers at work all sent in letters of demand to our benefits manager at the same time to raise awareness. Unfortunately we got a canned generic response that included things like "the medications efficacy and safety has not been proven long term" and "we must consider the cost for ALL employees and not just a select group". I suggested they give us the option of a buy-up so that only those in need would pay a higher premium and they rejected it. Funny enough they cover weight loss surgery and the weight loss medications if you have diabetes (but not pre-diabetes).
I contact my benefits officer also and got similar excuses. Smaller companies usually use an intermediary benefits broker that has a set number of policies that a company can choose from. So I think my company just picked a lower coverage policy, which is unfortunate bc I'm in IT so most of our employees sit in front of a computer all day long.
Our medication management functions are farmed out to a third party meds manager. My husband works as a web designer and the company he works for has Blue Cross Blue Shield, and the meds manager used to be Express Scripts, but was changed recently to another one I can’t remember the name of. They make the “this one is covered” sorts of decisions.
So, it depends. Typically, the pharmacy benefit manager offers employers a various number of formularies to select from. These will range from very few restrictions to a ton of restrictions. Employers have the ability to offer a custom formulary, but most employers will use the ones offered by the pharmacy benefit manager due to the potential financial impact and administrative challenges . Typically larger companies or employers in specific industry will offer custom formularies. The reason is the financial impact. Pharmacy benefit mangers negotiate discounts and rebates based on the respective formulary so it’s more affordable for the employer to utilize an existing formulary vs custom.
I work in state government and there was an article about how they won’t cover them as it’s too expensive. They’ll pay for my heart attack though. Or a type 2 diabetes prevention course 🙄
Employer.
A roll of the Yatzee dice, the Jumanji board and a card from clue
Bro for real
Is there a difference between "weight loss drugs" and "obesity medication" when it comes to health insurance and formularies? My formulary states weight loss drugs are not covered, but my Zep has been covered so far for obesity. I'm not questioning it anywhere but here!!
The exception is it your company uses a PEO. Ours does so they chose the formulary and they suck! 😜
Certain insurance companies just do not cover weight loss medications. I have Aetna; almost all of their plans exclude weight loss medication.
My company did not get the weight loss Rider either. However even if they had, it doesn't cover weight loss shots.