4.19.2023 Board Book

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One of the most significant milestones for obesity coverage came in 2022 when the federal Office of Personnel Management (OPM) released formal guidance, which states “that Federal Employee Health Benefit (FEHB) Carriers are not allowed to exclude anti-obesity medications from coverage based on a benefit exclusion or a carve out…” and that "FEHB Carriers must have adequate coverage of FDA approved AOMs on the formulary to meet patient needs and must include their exception process within their proposal.” In rolling out this new guidance, OPM is quite clear — emphasizing that "obesity has long been recognized as a disease in the US that impacts children and adults"… and that "obesity is a complex, multifactorial, common, serious, relapsing, and costly chronic disease that serves as a major risk factor for developing conditions such as heart disease, stroke, type 2 diabetes, renal disease, non-alcoholic steatohepatitis, and certain types of cancer.” Clearly, many national, federal, and state organizations now recognize obesity as a complex and chronic disease and worthy of coverage for comprehensive evidence-based treatment avenues. OMA believes that CMS should issue guidance that follows the numerous agencies of the federal government that have already categorized obesity as a disease and mirrors the coverage language surrounding obesity care issued by OPM in 2022. In addition to ensuring comprehensive coverage for intensive behavioral therapy and bariatric surgery, CMS must work toward addressing discriminatory benefit language surrounding AOM coverage. There has been tremendous advancement in both the understanding of obesity and the effectiveness and durability of treatment services since passage of the ACA. For example, the FDA has approved several AOMs throughout the last decade – with each new medication showing greater promise and results for both adults, and now children. For example, the largest clinical trial studying Semaglutide in adults showed an average weight loss of about 15% of initial body weight over 68 weeks and another study over the same length of time demonstrated that adolescents lost 16% of their initial body weight on average. Other medications in the FDA-pipeline include Tirzepatide, which is the first investigational medicine to deliver more than 20 percent weight loss on average in a phase 3 study. The Obesity Medicine Association has a number of clinical practice statements for your reference published in our journal Obesity Pillars. The medication statement can be found here Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022 - ScienceDirect CMS should also take note of the American Academy of Pediatrics (AAP) recently released evidence based recommendations on medical care for those age 2 and older as part of its new “Clinical Practice Guideline (CPG) for the Evaluation and Treatment of Children and Adolescents with Obesity.” The AAP guidelines contain key action statements, which represent evidence-based recommendations for evaluating and treating children with overweight and obesity and related health concerns. These recommendations include motivational interviewing, intensive health behavior and lifestyle treatment, pharmacotherapy, and metabolic and bariatric surgery. The approach considers the child’s health status, family system, community context, and resources. The comprehensive evidence-based BENEFIT DESCRIPTIONS IN EHB-BENCHMARK PLAN DOCUMENTS