GLP-1 (glucagon-like peptide-1) medication have been used as a remedy for kind 2 diabetes for over a decade, however newer types of these medication have gained widespread consideration for his or her effectiveness as a remedy for weight problems. Whereas these medication have offered new alternatives for weight problems remedy, they’ve additionally raised questions on entry to and affordability of those medication. These medication are costly when bought out of pocket, and protection in Medicaid, ACA Market plans, and most giant employer companies stays restricted, although numerous state Medicaid packages and different payers are re-evaluating their protection insurance policies. Increasing Medicaid protection of those medication might enhance entry for the virtually 40% of adults and 26% of kids with weight problems in Medicaid. On the similar time, expanded protection might additionally enhance Medicaid drug spending and put stress on total state budgets. In the long run, nevertheless, diminished weight problems charges amongst Medicaid enrollees might additionally lead to diminished Medicaid spending on persistent illnesses related to weight problems, corresponding to coronary heart illness, kind 2 diabetes, and forms of most cancers. This transient discusses Medicaid protection of GLP-1s, examines current developments in Medicaid prescriptions and gross spending on GLP-1s, and explores the potential implications of increasing protection weight problems medication for Medicaid packages.
Does Medicaid cowl GLP-1s for weight problems remedy?
States can determine whether or not to cowl weight problems medication below Medicaid. Underneath the Medicaid Drug Rebate Program, Medicaid packages should cowl almost all of a taking part producer’s Meals and Drug Administration (FDA)-approved medication for medically accepted indications. Nonetheless, weight-loss medication are included in a small group of medicine that may be excluded from protection. Although the statutory exception refers to brokers used for “weight reduction”, “weight problems medication” is used to check with this group of medicines on this evaluation. The FDA has permitted three GLP-1s for the remedy of weight problems, Saxenda (liraglutide), Wegovy (semaglutide), and Zepbound (tirzepatide), and state Medicaid protection of those is non-compulsory. Nonetheless, Medicaid packages need to cowl formulations to deal with kind 2 diabetes, together with Ozempic (semaglutide), Rybelsus (semaglutide), Victoza (lirglutide), and Mounjaro (tirzepatide). Wegovy, as of March 2024, should even be lined for stopping coronary heart assaults or strokes in adults with heart problems; nevertheless, this expanded label indication doesn’t impression this evaluation because it solely consists of knowledge by means of 2023. Notably, all weight problems medication are lined for youngsters below Medicaid’s Early and Periodic Screening, Diagnostic and Therapy (EPSDT) profit, although it’s much less clear how states are implementing and masking in observe.
Weight problems drug protection in Medicaid stays restricted, with 13 state Medicaid packages masking GLP-1s for weight problems remedy as of August 2024 (Determine 1). Twelve states in KFF’s annual finances survey reported protection of GLP-1s for weight problems remedy below FFS as of July 1, 2024, and North Carolina reported including protection in August of 2024. All 12 states that reported protection of GLP-1s as of July 1, 2024 additionally reported that utilization management(s) utilized, with the most typical being prior authorization (11 of 12 states) and/or BMI necessities (11 of 12 states). Eleven of the 12 states reported masking all three GLP-1s at the moment permitted for the remedy of weight problems (Saxenda, Wegovy, or Zepbound). Whereas the survey solely requested about FFS protection, MCO drug protection should be in step with the quantity, period, and scope of FFS protection. MCOs, nevertheless, might apply differing utilization controls and medical necessity standards until the state’s MCO contract specifies in any other case. Protection amongst different payers additionally stays restricted. Latest KFF evaluation additionally discovered most giant employer companies don’t cowl GLP-1 medication for weight reduction, protection in ACA Market plans stays restricted, and protection in Medicare is prohibited.
How have Medicaid prescriptions and gross spending on GLP-1s modified lately?
The variety of Medicaid prescriptions and gross spending on GLP-1s have elevated quickly lately, with each almost doubling from 2022 to 2023. General, from 2019 to 2023, the variety of GLP-1 prescriptions elevated by greater than 400%, whereas gross spending elevated by over 500%. Spending per prescription earlier than rebates reached greater than $900 per prescription in 2023. These costs and spending numbers don’t account for rebates, and states are possible receiving substantial rebates on these model medication. Whereas rebate knowledge for particular medication shouldn’t be publicly obtainable, Medicaid and CHIP Fee and Entry Fee (MACPAC) evaluation of FY 2020 knowledge discovered statutory rebates accounted for 61.6% of gross Medicaid spending on model medication. Additionally, amid rising criticism of the price of their medication, Novo Nordisk, the corporate that creates Ozempic and Wegovy, has stated that refunds and different charges (throughout all payers) account for about 40% of the price of the 2 medication. The GLP-1s on this evaluation nonetheless account for comparatively small shares of the overall variety of Medicaid prescriptions and spending earlier than rebates, although the shares are rising. By 2023, these medication accounted for 0.5% of all Medicaid prescriptions (up from 0.01% in 2019) and three.7% of all gross Medicaid spending (up from 0.9% in 2019).
Particularly, elevated utilization of Ozempic, Wegovy, and Mounjaro have contributed considerably to current development. Prescriptions and spending on Ozempic, permitted to assist management blood sugar ranges for adults with kind 2 diabetes in 2017 (Desk 1), have grown significantly from 2019 to 2023, almost doubling yearly since 2019. Wanting from 2022 to 2023, the most recent yr of knowledge obtainable, Wegovy (first permitted in 2021) and Mounjaro (permitted in 2022) additionally noticed substantial development, with prescriptions and gross spending for each medication rising twelvefold or extra. This evaluation consists of GLP-1 formulations permitted for weight problems remedy in addition to the identical formulations permitted for kind 2 diabetes (for extra info on how GLP-1s are recognized on this evaluation, see Strategies). From Medicaid knowledge publicly obtainable, there isn’t a means but to disentangle how a lot of the rising use of GLP-1s is expounded to remedy for diabetes versus weight problems, or a mix of each. As well as, the recognition and elevated demand for GLP-1s has led to drug shortages, generally inflicting folks to modify merchandise or ration doses or generally leaving people with out entry to wanted prescriptions. This will likely have implications for drug developments, although the FDA lately reported that GLP-1 provides are starting to stabilize.
How might the protection panorama of GLP-1s for weight problems remedy change?
Many state Medicaid packages are contemplating masking weight problems medication sooner or later however are involved about the price implications. KFF’s annual finances survey discovered that, amongst these states that don’t at the moment cowl weight problems medication, half reported they have been contemplating including protection, with just a few states reporting plans so as to add or increase protection in FY 2025 or later. When requested about the important thing elements contributing to their weight problems remedy protection determination, nearly two-thirds of responding states talked about price, although states are additionally weighing numerous different elements together with the necessity for legislative motion, adherence issues, medical standards growth, and potential unintended effects. Conversely, 4 in 10 states famous that constructive well being outcomes and longer-term financial savings on persistent illnesses related to weight problems have been key elements of their determination to cowl or take into account masking sooner or later together with rising enrollee entry and well being fairness, suggestions from suppliers, and skill to barter supplemental rebate agreements. States are possible contemplating varied price containment methods for these medication and should even be re-evaluating their broader method to weight problems remedy, together with using weight problems medicines together with different therapies corresponding to dietary counseling or behavioral remedy. Weight problems is attributable to a mess of complicated elements, and uptake of GLP-1s might enhance well being however wouldn’t tackle all the underlying contributors to weight problems.
Strategies
Variety of Prescriptions and Gross Spending Information: This evaluation makes use of 2019 by means of 2023 State Drug Utilization Information (SDUD) (downloaded in October 2024). The SDUD is publicly obtainable knowledge offered as a part of the Medicaid Drug Rebate Program (MDRP), and gives info on the variety of prescriptions, Medicaid spending earlier than rebates, and cost-sharing for rebate-eligible Medicaid outpatient medication by NDC, quarter, managed care or fee-for-service, and state. It additionally gives this knowledge summarized for the entire nation. The info don’t embody info on the variety of days equipped in every prescription. CMS has suppressed SDUD cells with fewer than 11 prescriptions, citing the Federal Privateness Act and the HIPAA Privateness Rule. This evaluation used the nationwide totals knowledge as a result of much less knowledge is suppressed on the nationwide versus state degree.
Figuring out GLP-1s: GLP-1 agonists included within the evaluation have been permitted for remedy of weight problems, Saxenda (liraglutide), Wegovy (semaglutide), Zepbound (tirzepatide) and corresponding formulations which will doubtlessly be used off-label for remedy of weight problems, Mounjaro (tirzepatide), Ozempic (semaglutide), Rybelsus (semaglutide), Victoza (liraglutide), mirroring one other current KFF evaluation. Different GLP-1 agonists with energetic components solely permitted for remedy of diabetes which have much less potential for off-label weight reduction use (corresponding to Bydureon BCise, Trulicity) weren’t included.
Limitations: There are just a few limitations to the estimates of Medicaid prescriptions and gross spending discovered on this evaluation, together with:
This evaluation examines the variety of Medicaid prescriptions within the knowledge and doesn’t regulate for days equipped by every prescription.
Gross spending and spending per prescription numbers don’t account for rebates.
The SDUD are up to date quarterly; a brand new quarter of knowledge is often launched, and the prior 5 years of knowledge are additionally up to date. This implies utilization and gross spending totals can differ relying on when the info is downloaded, and totals might not match different exterior sources or prior KFF evaluation because of this.
