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 is a significant clinical advancement for a specific group of plan members, it may not be the most cost-effective solution.
Koo emphasizes that the use of a continuous positive airway pressure (CPAP) machine remains the primary and more affordable treatment for most employees with obstructive sleep apnea. He suggests that Zepbound should be reserved for patients who require both weight management and cannot tolerate CPAP therapy. The expert warns against using Zepbound as a broad replacement for CPAP, which is significantly cheaper and immediately effective.
The financial implications of this decision are significant. Even with maintenance and supply costs considered, the total cost of treating obstructive sleep apnea with CPAP machines is still lower than the drug costs associated with Zepbound. Koo advises employers to carefully evaluate the cost-effectiveness of Zepbound's expanded treatment indication to avoid unintended financial burdens. He highlights the importance of clear criteria, such as documented sleep studies, body mass index thresholds, and prior authorization, to manage the indefinite financial implications of such therapies.
One of the challenges plan sponsors face is the lack of cost control based on indication within the current pharmacy benefit manager or carrier technology. Every new indication for Zepbound opens another door into the formulary for the same expensive drug, potentially leading to increased costs. This issue is particularly relevant as Zepbound's expanded use beyond weight management is expected to drive drug plan costs in 2026.
In conclusion, while the approval of Zepbound is a clinical breakthrough, plan sponsors must carefully consider its financial implications. By prioritizing cost-effective treatments and implementing clear criteria, employers can mitigate financial risks and ensure sustainable healthcare coverage for their employees.
