The coverage of GLP-1 agonists like Ozempic for weight loss under Medicaid programs, including Arizona's AHCCCS, is a multifaceted issue involving clinical effectiveness, cost considerations, and ethical dilemmas. While these medications have demonstrated efficacy in treating diabetes and related conditions, their use for weight loss alone is often restricted due to budgetary constraints and varying state policies.
GLP-1 Agonists: Benefits and Risks
GLP-1 agonists, such as Ozempic and Trulicity, have proven effective for individuals with type 2 diabetes, especially those with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease. The ADA now recommends other medications (including GLP-1 agonists) with or without metformin based on glycemic needs, that are appropriate initial therapy for individuals with type II diabetes with or at high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease. Beyond diabetes management, some GLP-1s have shown promise in reducing cardiovascular death, heart attack, and stroke in obese adults with cardiovascular disease, noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), and severe obstructive sleep apnea (OSA).
However, these medications are not without potential side effects. The most common adverse reactions are gastrointestinal-related, including loss of appetite, nausea, vomiting, and diarrhea. Additional concerns have emerged regarding patients needing surgery, as the delayed gastric emptying caused by these drugs may increase the risk of regurgitation and pulmonary aspiration during general anesthesia and deep sedation. Furthermore, all these products, when coverage is available, require a prior authorization (PA). There have been many requests for GLP-1 agonists (particularly Ozempic and Mounjaro) that appear to be intended for use outside of the FDA-approved indications for the product. The use of these medications is actively monitored and reviewed via PA requests to ensure these medications are used only per their FDA-approved indications. Requests for documentation to substantiate attestations made in the PA request process may be required.
Medicaid Coverage Policies: A State-by-State Approach
Under federal law, states generally must cover drugs approved by the Food and Drug Administration. Drugs for weight loss, including GLP-1s, are among the rare exceptions. Each state decides whether its program will cover these treatments.
Arizona is one of 32 states where Medicaid doesn’t cover drugs such as Trulicity and Ozempic without a diagnosis of diabetes, heart failure, high blood pressure or other related ailments. This means that many low-income Arizonans struggling with obesity cannot access these medications unless they develop a related health condition. This creates a paradoxical situation where individuals must become sicker to qualify for treatment, as highlighted by the case of Jesse, whose Medicaid coverage for Trulicity was discontinued once his diabetes was under control.
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Other states have taken different approaches. For example, North Carolina Medicaid will discontinue coverage for GLP-1s for the treatment of obesity, which is an optional benefit for Medicaid programs, effective Oct. 1, 2025, given shortfalls in state funding. However, GLP-1s will continue to be covered for the indications of diabetes, reduction in cardiovascular death, heart attack and stroke in obese adults with cardiovascular disease, noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) and severe obstructive sleep apnea (OSA).
The Cost Factor: A Major Obstacle
The high cost of GLP-1 agonists is a significant barrier to widespread Medicaid coverage. The Joint Legislative Budget Committee estimated that of roughly 2.1 million Medicaid recipients in Arizona, at least 282,000 and as many as 730,000 are obese and would qualify for a prescription. If 75% of them took advantage of the coverage, the committee estimated, the annual cost to state taxpayers would range from $192 million to $496 million. This substantial financial burden makes it difficult for states to justify covering these medications for weight loss alone, especially when facing budget constraints.
The hefty price tag for GLP-1s puts these blockbuster drugs out of reach for hundreds of thousands of low-income Arizonans, until their health deteriorates. As Sen. Bernie Sanders pointed out, the high prices charged by pharmaceutical companies could "bankrupt" Medicare and Medicaid.
Alternative Solutions and Future Directions
Despite the challenges, there are ongoing efforts to address the issue of access to weight-loss medications for Medicaid recipients. Some potential solutions include:
- Negotiating lower drug prices: Lawmakers and patient advocates are pushing for measures to lower the cost of GLP-1 agonists, making them more affordable for both Medicaid programs and individuals.
- Expanding coverage criteria: Some states may consider expanding Medicaid coverage to include individuals with obesity-related conditions, such as pre-diabetes or a high risk of cardiovascular disease, even if they don't have a formal diagnosis.
- Promoting preventative care: Investing in preventative care programs, such as nutrition counseling and exercise programs, could help reduce the need for weight-loss medications in the long run.
- Exploring alternative medications: Non-Incretin Mimetics class of drugs for treatment of obesity will continue to be managed through the PDL. Drugs in the Preferred status on the PDL include: diethylpropion, phendimetrazine and phentermine. These products do not require prior approval.
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