Obesity and the Federal Employee

OPM has informed FEHB insurance carriers that classifying obesity as a lifestyle condition or considering obesity treatment as cosmetic is not permitted under the federal health insurance program.

Are you seriously overweight? If so, the Office of Personnel Management (OPM) is trying to help you out.

In its latest letter to companies providing health insurance under the Federal Employees Health Insurance Program (FEHB), OPM observed that “many FEHB carriers exclude coverage of weight loss medications.”

As a result, the agency has concluded: “[W]e want to clarify that excluding 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’- is not permissible. In addition, there is no prohibition for  carriers to extend coverage to this class of prescription drugs, provided that appropriate safeguards are implemented concurrently to ensure safe and effective use.”

The letter also outlines preferred facilities for bariatric surgery. Bariatric surgery is weight loss surgery and includes procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with a gastric band or by removing of a portion of the stomach. OPM previously addressed bariatric surgery in 2013 and wrote that “updated standards and evidence-based guidelines strongly support considering bariatric surgery for patients with (specific BMI indications) plus one or more obesity-related chronic health conditions.”

Federal health insurance plans will not be able to exclude new drugs, Qsymia and Belviq, from obesity treatment according to John O’Brien, director of healthcare and insurance at OPM, by classifying obesity as a lifestyle condition or cosmetic treatment.

Obesity is a fact of life for many Americans. In fact, more than one-third of U.S. adults (34.9%) are obese according to the Centers for Disease Control (CDC). According to the CDC, non-Hispanic blacks have the highest age-adjusted rates of obesity (47.8%) followed by Hispanics (42.5%), non-Hispanic whites (32.6%), and non-Hispanic Asians (10.8%).

By state, obesity prevalence ranged from 20.5% in Colorado to 34.7% in Louisiana in 2012. No state had a prevalence of obesity less than 20%.  Thirteen states (Alabama, Arkansas, Indiana, Iowa, Kentucky, Louisiana, Michigan, Mississippi, Ohio, Oklahoma, South Carolina, Tennessee, and West Virginia) had a prevalence equal to or greater than 30%.

Obesity isn’t a situation in which a person needs to lose an extra five or 10 pounds for an adult. Obesity is defined as weight of at least 20% above your ideal weight taking into account your height, gender, and age. Twenty to forty percent over ideal weight is considered mildly obese; 40-100% over ideal weight is considered moderately obese; and 100% over ideal weight is considered severely, or morbidly, obese.

While those under the FEHB may be able to obtain weight loss drugs such as Qsymia through the FEHB when the program is modified to include these drugs, Qsymia is not inexpensive. Here is the average retail cost for this drug according to the CVS pharmacy website. Prices may differ among different pharmacies but this will provide an indication of the approximate cost. The per pill retail cost for a recommended dose of this drug is about $5.33.

  • Qsymia Low dose (3.75 mg phentermine/23 mg topiramate) — $139.99 per bottle
  • Qsymia Recommended dose (7.5 mg/46 mg) — $159.99 per bottle
  • Qsymia Three-quarter dose (11.25 mg/69 mg) — $194.99 per bottle
  • Qsymia Top dose (15 mg/92 mg) – $219.99 per bottle

The early estimates from the Food and Drug Administration put the cost of Belviq at $2.00 – $3.50 a pill. The dosage is two pills a day. Monthly estimates from other sources put the cost of Belviq at $150/month or $1800/year.

We do not know the impact on existing health insurance premiums by adding these weight loss drugs to the FEHB or what the cost of these drugs would be through the FEHB. If the drugs are added, the extra costs will be spread among all policyholders.

Even if the insurance picks up a substantial portion of the cost of a specialist to determine if the prescription is desirable for a specific individual, the co-pay for the drug, and the several follow-up visits with the specialist to monitor your health while taking the drug, you could still be spending a few hundred dollars per year. There are also side effects with these drugs that could impact a person’s decision to use them.

About the Author

Ralph Smith has several decades of experience working with federal human resources issues. He has written extensively on a full range of human resources topics in books and newsletters and is a co-founder of two companies and several newsletters on federal human resources. Follow Ralph on Twitter: @RalphSmith47