The increasing prevalence of obesity and its associated health risks have led to a growing demand for effective weight loss solutions. Glucagon-like peptide-1 (GLP-1) drugs, initially developed for managing type 2 diabetes, have emerged as a promising treatment for obesity. However, the high cost of these medications has raised questions about their accessibility, particularly for Medicaid recipients. This article examines Louisiana Medicaid's coverage policies for weight loss medications, specifically focusing on GLP-1 drugs like Wegovy.
Louisiana Medicaid Pharmacy Benefits
Louisiana Healthcare Connections manages pharmacy benefits for its members, committed to providing appropriate, high-quality, and cost-effective drug therapy. Coverage includes prescription medications and certain over-the-counter (OTC) medications when ordered by a Louisiana Medicaid-enrolled practitioner. However, the pharmacy program does not cover all medications.
The Louisiana Medicaid Single Preferred Drug List (PDL) outlines the drugs Louisiana Medicaid members can use if prescribed. This list, which applies to drugs received at retail pharmacies, is not exhaustive but highlights preferred medications in common drug categories. The PDL also includes a list of covered diabetic supplies when prescribed.
Access to Medications
To ensure continuous therapy, state and federal laws mandate that pharmacies dispense a 72-hour (3-day) supply of medication to members when a prior authorization (PA) has not been resolved. All participating pharmacies are authorized to provide this supply and will be reimbursed for the medication's ingredient cost and dispensing fee.
Age Limits and Safety Measures
Some medications on the Louisiana Medicaid Single PDL have age limits based on FDA-approved labeling, safety concerns, and quality standards of care. Louisiana Healthcare Connections prioritizes member safety through point-of-sale (POS) edits during prescription processing.
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Cost Considerations
The total amount members pay for medicine cannot exceed 5% of their family’s monthly income. Additionally, some diabetic supplies are covered for Louisiana Healthcare Connections members when prescribed by an in-network provider and filled by an in-network pharmacy, as detailed in the Louisiana Medicaid Single PDL.
Prescription Guidelines
Drugs may be dispensed up to a maximum of a 30-day supply for each new prescription or refill. Refills are typically allowed when 85% of the days' supply has elapsed, except for controlled medications.
Generic and OTC Medications
Generic drugs, which have the same active ingredient and work the same as brand-name drugs, usually have lower co-payments. Some OTC medications are covered when a licensed practitioner provides a prescription that meets all legal requirements. To determine if a specific OTC drug is covered, members can contact Louisiana Healthcare Connections.
Prior Authorization
Certain medications on the Louisiana Medicaid Single PDL may require prior authorization (PA). Practitioners or pharmacists can submit PA requests to Louisiana Healthcare Connections through covermymeds.com or the Louisiana Uniform Medicaid Prescription Drug Prior Authorization Form. These requests are reviewed based on criteria established by the Louisiana Department of Health’s DUR Board. If approved, Louisiana Healthcare Connections notifies the practitioner.
There may be limits on the amount of medication a member can receive at one time. If a practitioner has a medical reason to increase the amount, a PA can be requested from Louisiana Healthcare Connections.
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Specialty Drugs and Tobacco Cessation
Louisiana Healthcare Connections contracts with numerous pharmacies to ensure members have adequate access to specialty drugs. These drugs can be filled at any in-network pharmacy that can order them. The organization also contracts with some out-of-state pharmacies to fill limited distribution drugs (LDD) when approved by the Louisiana Department of Health.
For members over 18, some tobacco cessation medications, such as gums, lozenges, and patches, are covered with no pharmacy co-payment. These covered products are listed in the Louisiana Medicaid Single PDL, and a prescription is required for all tobacco cessation medications.
Wegovy and Weight Loss Medications
Wegovy, initially approved by the FDA in 2021 for treating obesity, has demonstrated significant efficacy in promoting weight loss. In March 2024, the FDA expanded Wegovy's indication to reduce the risk of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease and either obesity or overweight, when used in conjunction with a reduced-calorie diet and increased physical activity.
Louisiana Healthcare Connections covers Wegovy for this specific eligible population of members with established cardiovascular disease.
The Broader Context of GLP-1 Coverage
GLP-1 drugs mimic a hormone in the intestinal tract to balance the body’s blood sugar levels. While these drugs, including Ozempic, Wegovy, and Zepbound, have been available for years to help patients with diabetes, their popularity has surged for treating patients needing significant weight loss.
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This increased demand has led state Medicaid programs to grapple with whether to cover these drugs for weight loss, considering both equity and potential long-term health expenditure savings. Some states, like North Carolina, have opted to cover GLP-1s for obesity, citing the importance of providing necessary treatments and the potential for cost savings through reduced comorbidities.
Financial Implications and State Responses
Medicaid spending on GLP-1s for all conditions has increased substantially, from $597.3 million for approximately 755,000 prescriptions in 2019 to $3.9 billion for 3.8 million prescriptions in 2023, according to KFF. It’s important to note that this increase includes prescriptions for both obesity and diabetes, making it difficult to isolate the exact spending on obesity treatments.
The Biden administration proposed a rule to require Medicaid and Medicare programs to cover GLP-1s for weight loss, estimating a cost of $11 billion over 10 years for Medicaid. However, the Trump administration later scrapped this proposal.
States are exploring various strategies to manage the costs associated with GLP-1 coverage. These include negotiating rebates with drug manufacturers and seeking federal government contributions. Some states are also considering broader approaches to obesity treatment, combining medication with nutritional counseling and behavioral therapy.
Challenges and Considerations
Several factors influence state Medicaid programs' decisions on whether to cover obesity drugs:
- Cost: The high cost of GLP-1s is a major concern for many states.
- Equity: Ensuring access to effective treatments for all members, particularly those in underserved communities, is a priority.
- Long-term savings: Investing in weight loss treatments may reduce future healthcare costs associated with obesity-related comorbidities.
- Clinical criteria: Developing appropriate clinical criteria for prescribing these medications is essential.
- Adherence: Ensuring patients adhere to treatment plans is crucial for achieving positive outcomes.
- Potential side effects: States must consider the potential side effects of these medications.
Humana Healthy Horizons in Louisiana
Humana Healthy Horizons in Louisiana provides pharmacy benefits to its Medicaid recipients through Humana Pharmacy Solutions. This includes prescription medications and certain over-the-counter medications with a written order from a Humana Healthy Horizons provider. Some medications may require prior authorization and may have limitations.
Preferred Drug List and Copays
The Louisiana Department of Health (LDH) Single Preferred Drug List (PDL) guides which medicines Louisiana Medicaid recipients can use when prescribed. A Pharmacy and Therapeutics (P&T) Committee recommends medicines for inclusion on or removal from the PDL. Some medications are free, while adult members may need to pay a small copay for prescriptions based on the calculated state payment, not exceeding $3. The total copays for the month depend on the family’s income each month.
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