Carrier Letter 23-01 Prevention and Treatment of Obesity

FEHB Program Carrier Letter

All FEHB Carriers

U.S. Office of Personnel Management

Healthcare and Insurance

Letter Number 2023-01

Date: January 18, 2023

Fee-for-service [1] Experience-rated HMO [1] Community-rated HMO [1]

Subject: Prevention and Treatment of Obesity

Long recognized as a disease that impacts children and adults in the U.S.,

obesity is a complex, multifactorial, common, serious, relapsing, and costly

chronic disease that serves as a major risk factor for developing conditions

such as cardiovascular disease, type 2 diabetes, renal disease, non-alcoholic

steatohepatitis, and certain types of cancer. Obesity disproportionally affects

some ethnic and/or racial groups with non-Hispanic Black adults having the

highest prevalence, followed by Hispanic adults. There are also significant

psychosocial burdens experienced by those with obesity.

This Carrier Letter supplements and updates OPM’s previous guidance on

obesity treatment and coverage and supersedes guidance that was

previously issued to the extent it is inconsistent with this guidance. We

request that each Carrier review and update their medical policies

accordingly.

Background

OPM requested that plans propose specific services to reduce the incidence

of obesity in Carrier Letter 2011-05. The following year, Carrier Letter 2012-

09 outlined OPM’s expectation that FEHB plans offer programs to help

members attain and maintain a healthy weight. Both letters focused on

nutrition and exercise as primary options. In response, many plans refined

wellness activities, health coaching, nutrition counseling and disease

management to achieve a greater focus on obesity. Carrier Letter 2013-10

The Psychosocial Burden of Obesity

FEHB Program Carrier Letter 2023-01

provided detailed guidance on bariatric surgery and in 2014, OPM issued

Carrier Letter 2014-04 clarifying that it is not permissible to exclude weight

loss drugs from FEHB coverage on the basis that obesity is a “lifestyle”

condition and not a medical one or that obesity treatment is “cosmetic.”

Screening and Prevention

Recognizing that obesity continues to be a significant public health problem,

the United States Preventive Services Task Force (USPSTF) published

updated recommendations that all adults, children and adolescents, and

pregnant women be screened for risk factors associated with obesity. These

recommendations are referenced in:

• Healthy Weight and Weight Gain In Pregnancy: Behavioral Counseling

Interventions (2021)

• Healthy Diet and Physical Activity for Cardiovascular Disease

Prevention in Adults With Cardiovascular Disease Risk Factors:

Behavioral Counseling Interventions (2020)

• Weight Loss to Prevent Obesity-Related Morbidity and Mortality in

Adults: Behavioral Interventions (2018).

The USPSTF reaffirmed their recommendation that adults with a body mass

index of 30 kg/m

or higher be referred for intensive, multicomponent

behavioral interventions such as behavior-based weight loss and weight loss

maintenance interventions. The purpose of this recommendation is to

prevent or mitigate the health conditions associated with obesity. USPSTF

rated this recommendation as Grade B.

The USPSTF recommendation, Obesity in Children and Adolescents:

Screening (2017), is currently under review and expected to be updated by

Weight Management in Children and Adolescents: Interventions. The USPSTF

recommends that clinicians screen for obesity in children and adolescents 6

years and older and offer or refer them to comprehensive, intensive

behavioral interventions to promote improvements in weight status. As

stated in Carrier Letter 2022-03 adolescents experienced sharp increases in

their rates of weight gain during the COVID-19 pandemic, particularly

FEHB Program Carrier Letter 2023-01

school-aged children and those who already had obesity. The focus on

obesity coverage for children and adolescents is critical with more children

and families needing support in achieving and maintaining optimal weight for

long-term health.

As a reminder, FEHB Carriers must cover the full scope of required

preventive services recommendations as outlined in Carrier Letter 2019-01.

Specific to obesity, this means the benefit includes screening, and if

referred, the multicomponent, family centered programs that are part of

intensive behavioral interventions.

Pediatric screenings and preventive care endorsed by the American Academy

of Pediatrics Bright Futures Guidelines and Women’s Preventive Services

recommended in guidelines issued by the Health Resources and Services

Administration (HRSA) are also included in this requirement.

Treatment Options

Anti-Obesity Medications

Research in populations with diabetes, hypertension, and cardiovascular

diseases has shown that a 5% decrease in weight results in clinically

significant improvements in these obesity-related comorbid conditions.

Many of the Food and Drug Administration (FDA) approved anti-obesity

medications result in at least a 5% weight loss, with newer approved drugs

approaching a 20% weight loss. Timely management of obesity can be cost

effective, lower health risks, and prevent disease progression. The

landscape of pharmaceuticals available to treat obesity continues to evolve

and there are currently a variety of FDA approved medications available with

different mechanisms of action. The FDA indications for anti-obesity

medications reinforce that nutrition and physical activity regimens should

accompany drug treatment of obesity.

Treatment with anti-obesity medications is highly individualized and will

depend on the individual’s comorbidities, their current medication regimen,

and the potential for adverse effects.

FEHB Program Carrier Letter 2023-01

Anti-obesity medications also provide an important therapy option for

members who do not meet bariatric/metabolic surgery criteria (discussed

below) or those for whom the surgical option is otherwise deemed

inappropriate. Carriers should also support the use of anti-obesity

medications in consultation with the patient when there are ineffective

surgical outcomes such as insufficient weight loss or excessive weight regain

post-surgery.

In Carrier Letter 2022-03, OPM stated that FEHB Carriers are not allowed to

exclude anti-obesity medications from coverage based on a benefit exclusion

or a carve out. Carrier Letter 2022-02 outlines the requirements for Non-

Discriminatory Formulary Design, namely, that a non-discriminatory

formulary design does not have cost or access barriers imposed by disease

or condition.

FEHB Carriers must have adequate coverage of FDA approved anti-obesity

medications on the formulary to meet patient needs and must make

available their exception process to members. Carriers must cover at least

one anti-obesity drug from the GLP-1 class for weight loss and cover at least

2 additional oral anti-obesity drug options. As new anti-obesity drugs are

approved by the FDA, OPM expects Carriers to evaluate and update their

coverage of anti-obesity drugs. Carriers should provide access to a range of

obesity drugs on the formulary in order to satisfy OPM’s requirement in

Carrier Letter 2022-02 that Carriers must ensure non-discriminatory access

to safe, clinically appropriate drug therapy for members with chronic

conditions. This includes drug therapies indicated for adolescents age 12

years and older.

In cases where utilization management edits are applied, the process and

evidence-based criteria for coverage must be transparent, readily accessible,

and follow OPM required turnaround timelines for standard and expedited

reviews. We recognize the progress made in covering anti-obesity

medications; our goal is to have all Carriers offer adequate coverage.

FEHB Program Carrier Letter 2023-01

Bariatric/Metabolic Surgery

Surgical procedures to restrict the size of the stomach or induce

malabsorption of ingested calories were first introduced to treat severe

obesity in the 1950s. Currently, two of the most performed bariatric surgical

procedures are Roux-en-Y gastric bypass and sleeve gastrectomy. The major

effect of these surgeries is gastric restriction, causing weight loss, which is

then augmented by hormonal changes and leads to improved

cardiometabolic outcomes. Bariatric surgery can result in durable weight

loss along with improvement of obesity related conditions such as type 2

diabetes and cardiovascular disease. These procedures are now referred to

as metabolic surgery given the mechanism of action. Surgical techniques are

now more refined, improving the safety of these procedures. Evidence now

supports surgical procedures for adolescents.

Recent studies report both improved mortality and cardiovascular outcomes

with metabolic surgery in individuals with type 2 diabetes and obesity

(BMI>35) with suboptimal control of hyperglycemia, despite both optimal

medical therapy and lifestyle intervention.

Metabolic surgery is now

considered a treatment option in the 2022 guidelines

put forth by the

American Diabetes Association. OPM requests that plans promptly adjust

their criteria for metabolic surgery to reflect the most current guidelines.

For questions about this Carrier Letter or other aspects of comprehensive

obesity management for the FEHB Program, please e-mail your Health

Insurance Specialist.

Sincerely,

Laurie Bodenheimer

Associate Director

Healthcare and Insurance

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients

undergoing bariatric procedures – 2019 update

Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Medical Care

in Diabetes—2022