Many plans, including Medicare and Medicaid, have excluded coverage of weight loss treatments. Only this year, Medicare added coverage for diet/exercise counseling.
Attitudes toward obesity are in transition. Until recently, it was considered a "lifestyle" issue, like plastic surgery, or even estrogen treatments to relieve menopause symptoms. Recently, as we all know, study after study has confirmed the connection between obesity and cardiovascular issues. But even there, the medical and payer establishment has been cautious because weight loss is hard to maintain, and there has not been a clear statistical correlation with CV outcomes. The fact that many weight loss drugs to date have employed sympathomimetic pathways that speed up heart rate and raise blood pressure has also had a negative influence. Even Belviq, which uses a serotonergic pathway that has minimal CV impact, really only showed minimal improvement in CV markers, and there is still no data on outcomes.
But the big enchilada is diabetes. Something like a third of all Medicare spending goes toward diabetes care. Diabetes is a devastating, expensive disease, and there is now indisputable evidence that even small amounts of weight loss can have a big preventive and curative effect -- even after weight is regained. This is why the BLOOM-DM study is so important, and why Eisai paid a $20 million bonus for its inclusion in the label.
Eisai, like all big pharma companies, has whole teams of employees whose only job is to work with managed care providers and other payers to get formulary placement and preferred tier coverage for their drugs. Unfortunately, this takes time -- months to years. The insurance bureaucracy moves slowly and most companies only revise their benefits once once per year. But coverage of Belviq is inevitable, and chiefly because of the data showing stellar results for diabetes care and prevention.
It is actually an advantage for Belviq if policies for obesity drugs as a category remain restrictive and if Belviq gets coverage based largely on its role in treating diabetics and pre-diabetics, based on BLOOM-DM data. Qnexa doesn't have comparable data.