The increasing prevalence of obesity and the emergence of highly effective weight loss drugs have created a complex challenge for healthcare providers and insurers. MassHealth, the Massachusetts Medicaid program, is at the forefront of this issue, grappling with how to provide access to these medications while managing costs and ensuring responsible utilization. This article explores the evolving landscape of MassHealth coverage for weight loss drugs, examining the factors driving policy changes, the restrictions being implemented, and the broader implications for patients and the healthcare system.
The Rise of GLP-1 Drugs and Their Impact
Glucagon-like peptide-1 (GLP-1) receptor agonists, initially developed for the treatment of type 2 diabetes, have gained significant attention for their weight loss benefits. These drugs, including Ozempic (for diabetes) and Wegovy (for weight loss), work by suppressing glucagon, a hormone that raises blood sugar. Newer versions are stronger and more effective, and their popularity is skyrocketing. Despite having nearly identical chemical structures and sometimes containing the same active ingredients, these drugs are marketed under different names and come with a high price tag.
The increasing demand for GLP-1 drugs has had a significant impact on healthcare spending. In Massachusetts, GLP-1 prescriptions for commercially insured individuals surged from 0.5% in 2018 to 3.2% in the first nine months of 2023. This increase in prescriptions has led to a substantial rise in spending, with private insurers in Massachusetts projected to spend over $270 million on GLP-1 drugs in 2023, up from $125 million in 2022. A monthly supply of Wegovy had an average commercial price of $1,303 in 2023, not counting rebates the drugmaker gave insurers. (The average amount the consumer paid was $85 for a one-month supply.)
MassHealth's Evolving Coverage Policy
MassHealth began covering weight loss drugs when medically necessary in January 2024 after negotiating manufacturer rebates. However, the program is now implementing changes to its coverage policy in response to the rising costs and increasing demand. Starting in January 2025, MassHealth will require patients with obesity to first try an oral appetite suppressant before being approved for a GLP-1 drug. This move aims to ensure that less expensive options are considered before resorting to the more costly GLP-1 medications.
MassHealth has updated its list of covered drugs, effective 4/1/2023. The MassHealth Drug List is a listing of all of the drugs covered by MassHealth and WellSense. WellSense requires a 90-day supply be dispensed on certain drugs and allows up to a 90-day supply on others. Select drugs, like specialty drugs, are limited to a 30-day supply. The MassHealth Drug List is a listing of all of the drugs covered by MassHealth and WellSense.
Read also: The Fiscal Impact of Ozempic on MassHealth
Prior Authorization Requirements
Prior authorization (PA) is a common tool used by insurers to manage drug utilization and costs. In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. This designates a brand-name drug with FDA “A”-rated generic equivalents. PA is required for the brand unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
MassHealth requires prior authorization for many drugs, including GLP-1 agonists. The prescriber must obtain PA for the drug in order for the pharmacy to receive payment. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional criteria may apply depending upon diagnosis and/or requested medication. Members who have paid MassHealth pharmacy claims for a GLP-1 agonist within the last 90 days may bypass the phentermine trial.
National Trends in GLP-1 Coverage
MassHealth's decision to restrict GLP-1 coverage aligns with a broader national trend among state Medicaid programs. As list prices for these drugs continue to climb alongside increasing demand, many states are exploring ways to manage costs while ensuring access for those who need them most.
Nationally, state Medicaid outfits are restricting GLP-1 coverage as list prices consistently climb alongside increasing demand. But even these states may soon change their minds. Connecticut wants to roll back coverage, and Massachusetts’ MassHealth now limits weight-loss coverage to Zepbound with prior authorization.
Restrictions and Limitations
Private plans have imposed a range of requirements: prior authorization, enrollment in a diet or exercise plan, trying a less expensive drug first, or proof of weight loss for continued coverage. North Carolina’s state employee health plan stopped covering GLP-1 drugs for weight loss, saying continued coverage would have required a premium increase of $48.50 per subscriber per month. Blue Cross Blue Shield of Michigan this summer decided to stop covering GLP-1 drugs for weight loss, and the University of Texas stopped covering the injectables for weight loss for its employees in 2023.
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Medicare Part D plans, which are private plans that cover prescription drugs for seniors, are prohibited from covering weight loss drugs.
The Importance of Addressing Obesity
The increasing prevalence of obesity is a major public health concern. According to the Centers for Disease Control and Prevention, nearly 42 percent of American adults were obese between 2017 and 2020. Obesity is a risk factor for health problems including Type 2 diabetes, hypertension, and heart disease.
For many people, preventative measures like diet and exercise are insufficient. GLP drugs are remarkably effective, in many cases as effective as surgery. The Massachusetts Medical Society - and the national American Medical Association - have urged greater insurance coverage for weight loss treatments, including GLP-1 medications.
Alternative Approaches and Potential Solutions
Given the challenges of balancing access and cost, healthcare systems are exploring alternative approaches to obesity management. One innovative approach is a program Connecticut started for its state employee insurance plan. The state contracts with Flyte, which employs obesity specialists that see patients virtually (and soon in-person). Specialists create personalized weight loss plans for enrollees that often include non-medication interventions and lower-cost medicines before prescribing a GLP-1 drug. Flyte also provides education and support to patients on the drugs. According to Connecticut officials, the program has shown positive health effects while limiting the growth in prescriptions.
Addressing High Drug Prices
The ultimate solution is for the cost of these drugs to come down - which shouldn’t be impossible. Currently, GLP-1 drug prices in the United States can be four or five times higher than in other countries. Ozempic had a list price of $936 in the United States in August 2023 but less than $200 in countries including Japan, Canada, Switzerland, and Germany, and less than $100 in the United Kingdom and Australia.
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Senator Bernie Sanders, who chairs the US Senate Committee on Health, Education, Labor, and Pensions, has been pushing drug manufacturers to lower their prices. Research suggests generic versions could be manufactured at lower prices if legal, regulatory, and business hurdles are overcome.