GLP-1s - Thought leadership on coverage options

[youngbenefitslawyer]

Any insight, articles, or other resources anyone can share that would address the following questions:  (1) Can different plans sponsored companies a part of the same controlled group stop offering coverage for weight loss medications?; (3) Can companies within the same controlled group decline to offer coverage for weight loss medications while others offer it?  Even if they participate in the same welfare plan? (3) Can a plan limit or exclude new to market weight loss medications (non injectables)?

[Peter Gulia]

For your questions, is your assumption an ERISA-governed "self-funded" health plan that provides benefits without using a health insurance contract?

[youngbenefitslawyer]

Yes

[Artie M]

Just thoughts.  Generally speaking, group health plans are not federally required to cover weight loss meds.  Most of the plans I deal with would not cover them if simply for weight loss but might cover them if for some other medical issue, e.g., to control Type 2 diabetes or high blood pressure.  Most of those plans would require preapproval.  Employers, especially those with self-insured plans, have discretion to dermine their drug formulary. 

Since self-insured (and possibly one day with fully insured) offering the meds to one group versus another would be permitted if not discriminatory under §105(h).   If different between plans, do the separate plans satisfy 410(b) coverage testing?  If different for different groups within a plan, is the approach structured to meet 105(h)?  how does the employer classify the employee groups? etc....

[Peter Gulia]

Beyond Internal Revenue Code § 105(h), one might consider whether what each plan provides or omits, or what each combination of the § 414(b)-(c)-(m)-(n)-(o) employer’s plans provide or omit, discriminates by race, color, religion, sex, national origin, or another applicable civil-rights factor.

An employee-benefits lawyer might want to coordinate with one’s firm’s labor and employment practice.