OPM reminded carriers of a series of requirements for obesity and treatment beginning in 2011 including coverage of wellness activities, nutrition counseling and medications. Image: Dragana Gordic/Shutterstock.com
OPM has issued standards for FEHB carriers to meet in their coverage of obesity treatment and has encouraged them to better coordinate their prescription drug benefits with the Medicare Part D program, in light of recent changes to that program.
The letters come in advance of the annual “call letter” that sets terms for FEHB coverage in the following year and which kicks off the annual negotiating process that results in the announcement in the fall of premium rates and coverage for each plan.
In one of the notices, OPM reminded carriers of a series of requirements for obesity and treatment beginning in 2011 including coverage of wellness activities, nutrition counseling and medications. The letter reminds carriers that they “must cover the full scope of required preventive services recommendations” under prior guidance, including pediatric screening and preventative services under health industry guidelines.
Further, carriers “must have adequate coverage of FDA approved anti-obesity medications on the formulary to meet patient needs and must make available their exception process to members . . . As new anti-obesity drugs are approved by the FDA, OPM expects carriers to evaluate and update their coverage of anti-obesity drugs.”
In addition, “Metabolic surgery is now considered a treatment option in the 2022 guidelines put forth by the American Diabetes Association. OPM requests that plans promptly adjust their criteria for metabolic surgery to reflect the most current guidelines.”
The other letter addressed coordination with Medicare Part D, an add-on which most federal retirees don’t elect because FEHB plans already provide prescription drug coverage that “is, on average, comparable to or better than the standard Part D plan design.”
However, it said that the 2022 Inflation Reduction Act contained changes to Part D that “have made the environment more favorable for FEHB enrollees who are Medicare eligible to benefit from their Part D eligibility.” Those include a cap on the cost of insulin products, a waiver of cost-sharing for adult vaccinations effective this year; a cap on the growth of Part D premiums, elimination of a coinsurance requirement for catastrophic coverage and an expansion of subsidies starting in 2024; and a cap on enrollees’ out of pocket spending under Part D starting in 2025.
“These changes affecting the Medicare Part D benefit highlight the benefits of more closely coordinating the drug benefit offered to FEHB enrollees with Medicare,” OPM said, through a discount arrangement known as an Employer Group Waiver Plan.
“Offering Part D EGWPs that seamlessly coordinate with FEHB plans will provide FEHB annuitants the opportunity to take advantage of changes to the Medicare Part D program shown above. This coordination may make healthcare more affordable for FEHB enrollees by incorporating the manufacturer discounts required under Medicare Part D,” it said.
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