National pharmacy strategy lead at Medavie Blue Cross explains why the organization is targeting health outcomes in weight management program
When Medavie Blue Cross decided to launch their new weight management initiative, it wasn’t just responding to surging demand for anti-obesity drugs. They were attempting to correct what they view as a deeper flaw in how weight-related health is assessed and treated across the industry.
As Marie-Helen Dugal noted, the medical understanding of obesity has shifted from being viewed as a lifestyle issue to being recognized as a chronic disease. That change, she argues, should be reflected in how group benefit plans treat coverage for weight management medications.She also believes excluding obesity drugs is increasingly out of line with how benefit plans are structured today. That's what caused them to jumpstart their weight management benefits program.
“It’s meant to be more inclusive, to support the health of their employees,” emphasized Dugal, national pharmacy strategy lead at Medavie Blue Cros, underscoring that commitment to employee well-being should be central to why employers offer benefits in the first place.
Medavie Blue Cross’ rollout of the program came in direct response to concerns from plan sponsors and advisors following the explosive uptake of GLP-1 drugs like Wegovy. While Saxenda, a daily injectable drug, had seen moderate use in previous years, Wegovy, a weekly injectable, triggered a much broader uptake.
“We saw that the number of potential claimants and the demand for Wegovy was different,” said Dugal. “It was not just patients who were on Saxenda and looking to switch to an easier delivery schedule but really plan members who had never been on a weight management drug before, who had never maybe tried GLP-1s before some additional controls were put in place. Something like 70 per cent of Wegovy requests came from patients who had never taken another GLP-1 before or not a diabetic drug before.”
According to Dugal, early industry approaches to obesity drugs relied mainly on BMI as the entry criterion, since that was how regulatory approval had been defined. But using BMI alone raised serious concerns. Statistically, a large share of the Canadian population falls into higher BMI categories, which meant widespread uptake could overwhelm benefit plans.
"We were starting to hear concerns about this drug might be highly utilized. It might cause some risks into plans, and it might jeopardize the sustainability of plans," she said, noting that in the US, some large employers were forced to pull back coverage after costs became unmanageable.
That’s why Medavie deliberately moved away from using BMI alone as the basis for drug eligibility, arguing that “BMI is a number and not a marker of health,” she added.
Instead, the program looks at additional health measures to better determine who will benefit from weight management drugs. It also requires members to undergo behavioral or psychological interventions first, such as coaching or cognitive behavioural therapy.
Employers have been clear in their expectations, she said. They want to provide support for employees managing obesity, but they also want assurance that those employees are actively engaged in treatment. Their weight management benefits program addresses both concerns by requiring behavioural interventions alongside drug access.
“Medications aren’t a silver bullet,” she said. “It’s not going to do everything and be the cure-all.”
Another key feature of the program is the emphasis on health outcomes. Since obesity drugs can cost about $5,000 per year, Dugal explained that coverage must be tied to measurable improvements in conditions such as pre-diabetes or obesity-related complications. Otherwise, high utilization could undermine the sustainability of benefit plans.
This approach, she added, aligns closely with clinical obesity guidelines and stands apart from the industry’s tendency to focus solely on BMI.
To avoid a similar outcome, Medavie Blue Cross turned to its long-standing medication advisory panel, which reviewed global best practices and clinical guidelines. Dugal said the goal was to find a way for plans to continue covering obesity drugs without undermining affordability. She believes the resulting program reflects an evolution in Medavie Blue Cross’ approach, aligning more closely with obesity treatment guidelines rather than relying solely on regulatory criteria.
The insurer’s weight management program is ultimately designed to be available to all group plans that include coverage for obesity medications, though plan sponsors retain discretion over their benefit design.
While they promote broad access, "we recommend that the weight management drugs be covered as part of their drug plan without an annual or lifetime maximum," noted Dugal, emphasizing that because obesity is a chronic disease, many plan members may require ongoing treatment.
Additionally, imposing a cap on coverage, she argued, could result in treatment interruptions that ultimately worsen outcomes.
"If they go off of it and the weight comes back, that can lead to poorer health outcomes," she added.
Instead of capping costs through plan maximums, Medavie’s program uses prior authorization criteria and a structured trial period to manage utilization. Members must demonstrate both weight loss and improving health markers to continue receiving coverage. If early health outcomes are unclear, the program allows additional time to evaluate effectiveness.
Dugal also pointed out a gap in awareness among physicians and patients around the required behavioral and psychological supports. Some patients may have received informal coaching without realizing it met the program’s threshold, while others may need help accessing those services.
Dugal emphasized the decision not to raise the BMI threshold, as some insurers have done to restrict eligibility. She believes doing so would exclude people who may not meet an arbitrary number but are still at risk for serious health issues.
Early data shows the strategy is starting to pay off. Since implementing the program, Dugal noted that claim volumes have begun to level off.
“We can see that claims are stabilizing. We’re not approving as many requests as before because the criteria is different,” she said, adding that this shift supports long-term sustainability for plan sponsors.
To ensure plan sponsors understand how the program works and why it differs from conventional models, Medavie is leaning heavily on education efforts. Dugal noted that webinars have been a key tool in that process, and more are planned for the fall, along with additional speaking engagements.
“We want to get the word out there that there’s a way to make this benefit sustainable for plan sponsors and at the same time, put the focus back on the health outcomes,” she said.
