The recent approval of the weight loss drug Zepbound by Health Canada as a treatment for obstructive sleep apnea in obese adults has sparked a debate about financial risks for benefits plan sponsors. According to Joseph Koo, assistant vice-president of health solutions and national pharmacist at Aon, while Zepbound offers a genuine clinical advancement for a specific group of plan members, it may not be the most cost-effective solution.
Koo highlights the continued relevance of continuous positive airway pressure (CPAP) machines as the first-line treatment for most employees with obstructive sleep apnea. He emphasizes that Zepbound should be reserved for patients who require both weight management and cannot tolerate CPAP therapy, rather than becoming a broad replacement for the more affordable and immediate CPAP solution.
The financial implications of Zepbound's approval are significant. Even with maintenance and supply costs considered, the total cost of treating obstructive sleep apnea with CPAP machines remains lower than the drug costs associated with Zepbound. This disparity underscores the need for employers to carefully evaluate the cost-effectiveness of Zepbound's expanded treatment indication.
To mitigate financial risks, Koo suggests implementing clear criteria, such as documented sleep studies, body mass index thresholds, and prior authorization. These measures are crucial, as they involve indefinite therapies with long-term financial implications for health plans. Additionally, plan sponsors must address the challenge of pharmacy benefit manager or carrier technology that fails to control costs based on indication, as each new indication opens a door to the formulary for the same expensive drug.
In summary, the approval of Zepbound raises important considerations for benefits plan sponsors. By carefully assessing cost-effectiveness and implementing appropriate criteria, employers can navigate the financial risks associated with this new treatment indication.
