The landscape of Medicaid coverage for weight loss medications is constantly evolving. While these drugs offer promising solutions for managing obesity and related health issues, questions about access, affordability, and budget constraints continue to shape coverage policies across different states.
The Role of GLP-1s in Obesity Treatment
GLP-1 (glucagon-like peptide-1) drugs, initially developed for treating type 2 diabetes, have emerged as effective treatments for obesity. These drugs have gained popularity for their ability to promote significant weight loss, offering new possibilities for addressing the obesity epidemic. However, their high cost and limited coverage have sparked debate about equitable access and financial sustainability.
Optional Coverage and State Decisions
Under the Medicaid Drug Rebate Program, states have the option to exclude weight-loss drugs from coverage. Despite this, a growing number of state Medicaid programs are re-evaluating their policies and considering coverage for obesity drugs. As of August 2024, 13 state Medicaid programs covered GLP-1s for obesity treatment.
States that are considering covering obesity drugs in the future are weighing factors such as cost, the need for legislative action, adherence concerns, clinical criteria development, and potential side effects. Conversely, factors that support coverage include positive health outcomes, longer-term savings on chronic diseases associated with obesity, increased enrollee access and health equity, recommendations from providers, and the ability to negotiate supplemental rebate agreements.
North Carolina Medicaid: Changes in Coverage
North Carolina Medicaid, encompassing both NC Medicaid Direct and NC Medicaid Managed Care, has announced changes to its coverage of GLP-1s for weight management.
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Discontinuation of Coverage for Obesity Treatment
Effective October 1, 2025, NC Medicaid will discontinue coverage for GLP-1s when used solely for the treatment of obesity. This decision is driven by shortfalls in state funding, as obesity treatment is considered an optional benefit for Medicaid programs.
Continued Coverage for Other Indications
Despite the discontinuation of coverage for obesity treatment, GLP-1s will continue to be covered for specific FDA-approved indications, including:
- Diabetes
- Reduction in cardiovascular death, heart attack, and stroke in obese adults with cardiovascular disease
- Noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis in adults
- Moderate to severe obstructive sleep apnea (OSA) in adults
Specific Drug Coverage Changes
- Wegovy, Zepbound, and Saxenda: These drugs will be removed from the Preferred Drug List (PDL) as an off-cycle change, effective October 1, 2025.
- Saxenda: Coverage for Saxenda will be discontinued for all indications.
- Wegovy and Zepbound: Coverage for Wegovy and Zepbound will be managed through prior authorization, using clinical criteria established by the state for the approved indications.
- Non-Incretin Mimetics: The Non-Incretin Mimetics class of drugs for obesity treatment will continue to be managed through the PDL. Preferred drugs in this class, such as diethylpropion, phendimetrazine, and phentermine, will not require prior approval.
Prior Authorization Requirements
Providers will need to obtain a new prior authorization for beneficiaries receiving Wegovy and Zepbound for the approved indications, effective October 1, 2025. Current prior authorizations will no longer be valid after September 30, 2025. Prior authorization requests can be submitted beginning October 1, 2025.
No Changes for Diabetes Treatment
There will be no changes to coverage for GLP-1 medications used for the treatment of diabetes. Additionally, Weight Management (Non-Incretin Mimetics) will still be covered as listed on the PDL.
Pennsylvania Medicaid: Coverage Criteria
In Pennsylvania, Medicaid consumers prescribed medication for the treatment of obesity may be able to get these medications covered if they meet certain criteria. Medicaid coverage of these weight loss drugs is available to participants who meet the prior authorization criteria. Importantly, this includes people who have both Medicaid and Medicare, known as “dual eligibles”. Typically, Medicaid does not provide drug coverage for dual eligibles. Dual eligibles must get their medications covered through Medicare Part D (Medicare’s prescription drug benefit). However, Medicaid can cover certain medications excluded from the Medicare Part D benefit. Medicare Part D coverage rules specifically exclude coverage of prescription medications used solely for weight loss. Another example of excluded Part D drugs that are covered by Medicaid for dual eligibles are over-the-counter medications.
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In order for Medicaid to cover these new weight loss drugs, a person’s doctor must submit a prior authorization request detailing that the patient meets the coverage criteria. Generally, to get these drugs covered, adults over age 18 must have a body mass index (BMI) of 30 or higher (or 27 or higher with certain additional requirements), and they must have at least one weight-related health condition. People who have diabetes or have used a diabetes drug in the previous 120 days have an additional requirement: they must try and fail treatment on one of the preferred diabetes treatment versions of the weight loss drugs, or another preferred diabetes drug in the same drug class (GLP-1 receptor agonists).
People have a right to appeal if Medicaid denies coverage for the new weight loss drugs after a doctor submits the prior authorization showing the patient meets the criteria.
Factors Influencing Coverage Decisions
Several factors influence state Medicaid programs' decisions regarding obesity drug coverage:
- Cost: The high cost of GLP-1s is a major concern for state budgets.
- Budget Constraints: Shortfalls in state funding can lead to the discontinuation of optional benefits like obesity treatment.
- Health Outcomes: The potential for positive health outcomes and long-term savings on chronic diseases associated with obesity can support coverage decisions.
- Access and Equity: Expanding coverage can increase access to these medications for a larger population, promoting health equity.
- Utilization Controls: States often implement utilization controls, such as prior authorization and BMI requirements, to manage costs and ensure appropriate use.
Trends in GLP-1 Utilization and Spending
The use of GLP-1s has increased significantly in recent years, leading to a corresponding rise in Medicaid spending. From 2019 to 2023, the number of GLP-1 prescriptions increased by more than 400%, while gross spending increased by over 500%. Increased utilization of drugs like Ozempic, Wegovy, and Mounjaro has contributed substantially to this growth.
The popularity and increased demand for GLP-1s have also led to drug shortages, causing people to switch products or ration doses, or sometimes leaving individuals without access to needed prescriptions.
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Potential Side Effects and Warnings
Wegovy carries potential risks and side effects that patients should be aware of:
- Possible thyroid tumors, including cancer: Patients should report any lumps or swelling in the neck, hoarseness, trouble swallowing, or shortness of breath to their healthcare provider.
- Harm to unborn babies: Wegovy may harm an unborn baby, and women who are pregnant or planning to become pregnant should inform their healthcare provider.
- Breastfeeding: It is important to inform healthcare providers if you are breastfeeding or plan to breastfeed.
- Drug interactions: Patients should inform their healthcare provider about all medications they are taking, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
- Pancreatitis: Patients should stop using Wegovy and call their healthcare provider right away if they have severe pain in their stomach area (abdomen) that will not go away, with or without vomiting.
- Gallbladder problems: Wegovy may cause gallbladder problems, including gallstones.
- Increased risk of low blood sugar (hypoglycemia): This is especially a concern for those who also take medicines for diabetes such as insulin or sulfonylureas.
- Kidney problems (kidney failure): Diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration), which may cause kidney problems to get worse.
- Severe stomach problems: Stomach problems, sometimes severe, have been reported in people who use Wegovy.
- Serious allergic reactions.
- Change in vision in people with type 2 diabetes.
- Increased heart rate: Wegovy can increase heart rate while at rest.
- Depression or thoughts of suicide: Patients should pay attention to any mental changes, especially sudden changes in their mood, behaviors, thoughts, or feelings.
- Risk of food or liquid getting into the lungs during surgery: Wegovy may increase the chance of food getting into the lungs during surgery or other procedures that use anesthesia or deep sleepiness (deep sedation).
Resources for Checking Coverage and Costs
Novo Nordisk, the maker of Wegovy, offers a platform where individuals can check their insurance coverage for Wegovy and access savings offers. The platform asks for information such as insurance details, personal information, and healthcare provider details.
If insurance coverage is not provided or immediate coverage details are unavailable, the platform may share options that may help. It also provides a downloadable guide to help individuals talk to their healthcare professional about Wegovy and coverage options.