The workers compensation industry has mostly rejected covering increasingly popular weight-loss injections, but that hasn’t stopped doctors treating injured workers from prescribing the drugs to patients, according to experts.
Sedgwick Claims Management Services Inc. saw a 46% increase in prescriptions for drugs such as Ozempic, WeGovy, Mounjaro and Zepbound, but “very few” are approved by workers compensation payers, according to Teresa Bartlett, the third-party administrator’s managing director and senior medical officer, who is based in Southfield, Michigan.
Other companies working with injured workers are seeing a surge in interest.
“There’s a growing trend of doctors prescribing them in cases where improving overall health, like weight loss or better diabetes management, could help with injury recovery, especially before surgeries,” said Ryan Hamm, a Hillard, Ohio-based clinical pharmacist at CorVel Corp.
Obesity, one of the most common comorbidities among injured workers, can impede injury recovery, but comp experts have said potential side effects of the weight-loss medications, including cancer and stomach paralysis, outweigh the benefits for the comp system, which could see side effects attached to the claims.
Silvia Sacalis, Tampa, Florida-based vice president of clinical services for Healthesystems LLC, said that while some patients may need to lose weight for surgeries related to their work injuries, the long-term effects, the required monitoring and lifestyle changes needed to maintain weight loss, and high costs of the brand-name drugs have comp payers rejecting most of the prescriptions.
Johnny Taylor, Tampa, Florida-based assistant vice president, ancillary networks, pharmacy, at GBCare, estimates the drugs represent less than 0.5% of pharmacy costs. That’s mostly “because many cases are not reasonable from a compensability standpoint,” he said.
Ms. Bartlett said acceptance of the prescriptions is case-by-case, but usually the drugs are not covered. “We have a specific plan with our pharmacy benefit management companies, and we are having clinicians look at each and every one of these” prescriptions, she said.
The comp legal system, which must adhere to formularies and other regulations in several states, is quiet on the issue, according to experts. “There are currently no specific workers compensation guidelines that directly support the use of (the drugs) for weight loss,” Nikki Wilson, Omaha, Nebraska-based senior director of clinical pharmacy services at Enlyte LLC, wrote in an email.
“In certain cases weight-loss treatments might be considered for coverage, including medications, if obesity is determined to be a contributing factor to a work-related injury or if weight loss is deemed necessary for the treatment and recovery process,” she wrote.
“In such cases, the use of (the drugs) for weight loss should be evaluated on a case-by-case basis, considering the individual’s specific circumstances and the recommendations of their health care provider.”
This article was first published in Business Insurance.
