Understanding insurance coverage policies for incretin mimetics for weight management.

Objectives: Given the wide variation in insurance coverage for incretin mimetics for weight management (IMWM) in the US, we aimed to understand (1) coverage policies for IMWM and influencing factors, (2) coverage policies for other weight management treatments, and (3) opportunities to support weight management while constraining health care costs.

Study design: Qualitative study.

Methods: Participants were leaders and high-level employees from large health insurance organizations in the US. Our aim was to survey 20 participants, 10 from organizations that covered IMWM and 10 that excluded coverage for IMWM. Participants completed a 30-minute interview. Interviews were audio recorded, transcribed verbatim, and analyzed using directed content analysis.

Results: Twenty individuals completed an interview; 9 interviewees were from organizations that covered IMWM at the time of the study, and 11 were from organizations that excluded coverage for IMWM. We identified 5 key themes: (1) high cost as the primary barrier to coverage of IMWM, (2) perception of obesity as a lifestyle choice, (3) current or planned use of varied utilization management strategies to limit initial and ongoing prescribing of IMWM, (4) coverage for lifestyle-change programs to support weight management, and (5) perceived responsibility of pharmaceutical companies to lower list prices for IMWM to enable broad coverage and advance health equity.

Conclusions: High cost of IMWM is the primary limiting factor in coverage policies. There is variability in plan design, with utilization management strategies that aim to reduce near-term spending. Health plan leaders call on pharmaceutical companies to reduce list prices to increase equitable access to IMWM.