Pezalla likened the program to the CMS' coverage with evidence development policy, which allows new medical technologies to be reimbursed by Medicaid and Medicare while studying the impact on outcomes. Aetna released a clinical policy bulletin in November 2012 that said both drugs are medically necessary if patients meet the medications' criteria. Not all plan sponsors cover the drugs in their benefit plans, though, Pezalla said.
As part of the Aetna program, the drugs, which usually cost about $200 a month, will be covered in the preferred brand tier. Copays for this tier range from about $30 to $50 depending on the plan. Some patients may take the drug for a year or longer.
The program also will include outreach to physicians and patients about a patient's covered weight-loss options.
Many doctors and patients have taken a “wait-and-see” approach to the drugs, which may be one reason why adoption has not been as high as expected, Pezalla said. Other reasons may include patients' perceptions that the drugs are not covered by health plans or concerns about the effectiveness of the treatments.
“There's some caution and also some recognition that drugs alone are not the solution,” he said.
The drug companies will provide participating patients with access to websites and mobile apps, as well as some phone-based activities.
“Insurers and employers recognize and understand the staggering costs of obesity and weight-related co-morbidities; they are analyzing ways to reduce these costs and need to generate data to address this problem in a cost-effective way,” a Vivus spokesman said.
Qsymia, which became available in about 31,000 retail pharmacies in July, reported $6.4 million net product revenue from July through September. About 109,000 prescriptions for the drug were dispensed during the same three-month period.
However, other weight-loss drugs may be approved by the FDA this year. Employers will be looking for guidance about whether the drugs and comprehensive weight-loss programs produce results. Examining the first-year results of the pilot program will likely impact how Aetna makes benefit decisions, Pezalla said.
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