Health Plan Designs to Help Manage Obesity

Filed under: Benefits

In the United States, 40 percent of adults are clinically obese, according to the Centers for Disease Control and Prevention (CDC). Obesity is one of leading contributors to chronic health conditions and is a major factor in rising healthcare costs.

Employer-sponsored health insurance should be particularly attentive to the growing issue of obesity for the simple reason that it represents the majority of Americans:

• Employment-based insurance coverage - 53%
• Medicare - 18%
• Medicaid - 18%
• Individual market - 10%
• TRICARE (Military) - 2%

The most common metric for determining obesity is a body mass index (BMI) calculation above 30. A secondary factor is waist circumference. Men with a waist circumference higher than 40 inches and women at 35 inches or greater are considered obese.

Coverage Options

The core offerings by insurers and health maintenance organizations (HMOs) tend to include medical and surgical benefits, as well as an optional obesity-oriented rider available for purchase at an additional premium.

Key features of weight-control benefits include:

• A dedicated wellness coach matched to member preference for gender, specific background, and language
• Weight counseling – coaching support to develop individual goals and a tailored action plan
• Access to a support group with common goals
• Therapy options for behavioral modification
• Coverage for a fixed number of counseling phone/video calls
• Nutrition and meal preparation plan
• Physical exercise plan with discounted resources
• The integration of online and offline tools and resources (e.g., calculators, trackers, articles, smart scales) to promote awareness, education, and engagement
• Onsite access to biometric screenings
• Team and individual rewards programs
• Long-term maintenance plan
• Access to GLP-1 or other weight-loss medications
• Health plan coverage for bariatric surgery

GLPs

Glucagon-like peptide-1 receptor agonists (GLP-1) is a class of drugs approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes and obese patients. Nearly 12 percent of Americans – approximately 40 million people – have used a GLP-1 specifically to help them lose weight. The key advantages of GLP-1s are that they are highly effective and have  fewer side effects compared to other weight-loss medications.

However, GLP-1s are also very expensive, with a list price of around $1,000 or more per month.

As part of its Make America Fit Again initiative, in November 2025 the Trump administration announced that it had negotiated lower prices with Eli Lilly and Novo Nordisk for GLP-1 medications bought on a new direct-to-consumer platform. The website, branded TrumpRx, is projected to launch in early 2026 (purchases will still require a prescription from a health professional). The White House stated that the price of Ozempic, Wegovy, and Zepbound GLP-1 injectables would drop to $350 a month and, pending FDA approval, a pill version of Wegovy may become available for just $150 at TrumpRx.

Plan sponsors offering coverage for GLP-1s can help keep their costs down by implementing standard plan design tools such as:

• Prior authorization
• Quantity limits
• A deductible specific to the category of weight-loss prescription drugs
• BMI requirements for coverage
• Step therapy (i.e., fail-first program) for weight loss
• Restricting GLP-1s available in the plan formulary
• Limiting coverage to pharmacy compounded GLP-1s

Bariatric Surgery

Bariatric surgery is an operation intended to restrict stomach size to diminish obesity by reducing the absorption of nutrients. The three different types of bariatric surgical procedures are: a gastric bypass, an adjustable gastric band, and a sleeve gastrectomy. These techniques have yielded an average loss of 55 percent of excess weight and offer a positive impact on other chronic conditions.

Considerations

Employers interested in developing weight-conscious health plan designs should include coverage for a variety of obesity-related products and services. Consider health intervention programs and how to make these benefits sustainable over time. After all, weight control is not an acute condition; it requires long-term behavioral changes.

Plan sponsors should also assess the potential return on investment for a comprehensive obesity plan, relative to its cost. Remember though, ROI is characterized not only by a reduction in expenditures, but also by plan utilization, effectiveness, and perceived value by the workforce.

Recognize that a plan design specifically branded as obesity-specific could set up unrealistic expectations among participants. Many people want to lose weight for cosmetic reasons, while the purpose of the program is to foster improved health. As such, workers who are overweight but not clinically obese may sign up with the expectation of losing far more than the five percent to 10 percent weight reduction necessary to reduce health risk. Furthermore, they may not qualify for program features designed for the obese.

There should be an education and stratifying component in the plan design that matches the appropriate benefits to participants in order to manage expectations. This can help mitigate any disappointment and discouragement, for example, of someone moderately overweight who does not qualify for GPL-1s or bariatric surgery. For participants who meet the standard for obesity, it should also be clear that there is a structured multi-step program that must be followed to avoid signing on for immediate access to expensive drugs or surgery.

In fact, it is important for plan sponsors to design obesity benefits tailored to the organization’s specific needs, budget, and company culture. It should by no means be marketed as an easy fix to being overweight, but rather as a structured benefit plan designed to address the health impacts of being severely overweight – including the commitments required of participants.

Because most Americans receive health insurance through an employer-sponsored plan, developing plan designs with an obesity component has the potential to be both popular and effective.

 

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