Anti-obesity drug coverage for state workers would cost more than $20 million a year, even including medical savings from weight loss, a state agency told a board that will meet Wednesday to approve benefit changes for next year.
Despite pleas from doctors and patients, the Department of Employee Trust Funds recommended that the Group Insurance Board, which oversees benefits for state workers, not approve coverage of anti-obesity drugs.
People are also reading…
The drugs include newer injections, such as Wegovy and Zepbound, that have helped some obese people lose more weight than older drugs or through diet and exercise. Their list prices are about $900 to $1,300 a month. Medicare and many employers’ private insurance plans don’t cover the drugs. In Wisconsin, Medicaid has limited coverage.
The Group Insurance Board has been discussing the possibility of covering the medications since May 2022. Doctors and patient groups have urged coverage, even for just a limited group of patients who most need the drugs. The board determines health benefits for about 245,000 workers, retirees and their dependents, for the state and some local governments and school districts. Most live in Dane County.
ETF, which administers the benefits, has said the drugs are too costly, with questionable long-term payoff. The agency has cited a state law saying it can’t add benefits that would increase premiums unless they are mandated.
In 2025, if the drugs were covered, an estimated 7,406 workers or family members would take them, ETF said in a Jan. 24 memo to the board, based on an analysis from the consulting firm Segal. That would cost $24.8 million, offset by $3.5 million in medical savings from weight loss, for a net cost of $21.3 million, the memo said.
In 2026, an estimated 9,315 ETF members would take the drugs, costing $39.7 million. With medical savings of $12.4 million, the net cost would be $27.3 million, ETF said. Only starting in 2030, when the coverage would cost $60.1 million and savings would reach $40.4 million, would the net cost drop slightly below $20 million.
“The cost of weight-loss drugs has not lowered, and independent scientific studies have not been published to show the there is an offset of the cost of the drugs with long-term medical savings,” the ETF memo said.
The analysis assumes 25% of people with a body mass index of 35 or greater — considered to be moderate or severe obesity — would take the drugs. For someone 5-foot-9, that’s 240 pounds or more. The share of people taking the drugs would grow by 5 percentage points a year, but more than half would stop taking the drugs after a year, according to the analysis.
In an earlier analysis, Segal said ETF would spend $9 million to $14 million a year to get $2 million in medical savings from weight loss.
The drugs can cause side effects, such as nausea, diarrhea and hair loss, according to the Food and Drug Administration. An initial evaluation found no evidence of increased risk of suicide, the FDA said last month.
In 2020, ETF started covering weight-loss surgery for people with a BMI of 35 or greater.
Doctors say coverage needed
Dr. Samantha Pabich, a UW Health endocrinologist who treats many patients with obesity, said the newer drugs can help obese people lose a higher percentage of their body weight than older drugs. That can help control diabetes, high blood pressure, high cholesterol, sleep apnea, pain and other conditions, and prevent the need for treatments such as home oxygen therapy and liver transplants, she said.
“We really should have some ability to help the people who really need help right now,” Pabich told the Wisconsin State Journal.
ETF could limit drug coverage to obese people with two or more obesity-related conditions, which would reduce the cost while helping those who most need the drugs, she said.
Not all patients qualify for weight-loss surgery or want it, and many have repeatedly tried diet and exercise with little long-term effect, Pabich said.
“Weight loss is kind of against human evolution,” she said. “We were designed to not lose weight because that meant we were starving in a famine.”
Dr. Michelle Poliak-Tunis, a pain and rehabilitation specialist at UW Health, wrote to ETF last year, noting that Illinois, Indiana, Iowa, Michigan and Minnesota cover anti-obesity drugs for public workers.
Tricia Sieg, ETF’s pharmacy benefits program manager, said that is correct, but some states set limits. Minnesota, for example, requires workers to pay the full cost of the drugs for three months and lose 5% of body weight before coverage begins, Sieg said.
Dr. Leslie Golden, a family medicine provider in Watertown and president of the Wisconsin Obesity Society, said expensive treatments for cancer and other chronic diseases are typically covered by insurance without required proof of cost savings. “Obesity should be treated with the same level of seriousness and without the additional burden of proving cost savings, especially when the medical community recognizes it as a disease,” she said.
How the drugs work
Wegovy, a version of semaglutide, was approved by the Food and Drug Administration for weight loss in 2021. It mimics a hormone in the gut, called GLP-1, which makes people feel full. Ozempic, another version of semaglutide, was approved for diabetes in 2017 and is sometimes used for weight loss.
Zepbound, or tirzepatide, was approved for weight loss last year. It activates receptors of GLP-1 and another hormone, GIP, to reduce appetite and food intake. Mounjaro, which is also tirzepatide, was approved for diabetes in 2022.
A generic version of another GLP-1 drug — Saxenda, or liraglutide — could be on the market by June, which could bring prices down. Generic versions of semaglutide and tirzepatide aren’t expected until patents expire in 2032 or later.