NC State Health Plan is ending coverage of weight-loss drugs. What members need to know [The Charlotte Observer]

Leaders of the NC State Health Plan have voted to remove coverage of a class of obesity drugs called GLP-1s, which have generated publicity for their remarkable effectiveness in helping people lose weight and have become widely popular among the plan’s members.

The decision, approved last week, will affect about 24,000 State Health Plan members who currently take medications like Wegovy and Saxenda for weight loss, and who may not be able to front the expensive out-of-pocket cost.

These members may gain back weight they’ve lost, as these medications are typically recommended for long-term use.

Will it affect you? Here’s what you need to know.

How is coverage of weight loss drugs changing?

On Thursday, the State Health Plan’s leadership voted to remove obesity GLP-1s from the plan’s list of covered drugs.

The change begins April 1 and will affect prescriptions for Wegovy, Saxenda and any other future drugs in this class that are approved for weight loss.

That means the plan will no longer subsidize any part of the medication’s price. There is no provision for requesting an exception.

Currently, plan members who are still able to get prescriptions pay $30 or $47 a month on average for them, depending on what coverage plan they are enrolled in.

In October, the State Health Plan board voted to impose a moratorium on new prescriptions of Wegovy, solely for weight loss purposes, effective Jan. 1.

Members who already had prescriptions prior to Jan. 1 will continue to be able to access this drug until April.

Beginning in April, all members will need to pay about $1,350 a month out-of-pocket to fill prescriptions of Wegovy or Saxenda, according to Deputy Treasurer Frank Lester.

Why are weight-loss drugs not covered by the State Health Plan insurance?

State Health Plan leaders said they voted to cease coverage to rein in “unsustainable” spending on drugs like Wegovy.

The growing popularity of the drugs, along with the hefty price tag, have made coverage too costly, NCSHP staff have said.

According to Lester, the drug’s usage jumped from 8,400 people in 2021 to 24,750 in 2023. Before rebates, this amounted to over $43 million in 2021 and over $170 million in 2023.

The plan spent more on Wegovy than any other medication this year, the plan’s pharmacy benefit manager told the board of trustees in August.

Representatives for Novo Nordisk, the manufacturer of Wegovy, have argued that the upfront cost of the drugs pays off in the long run because patients on the medications are less likely to develop other costly chronic conditions like Type 2 diabetes and heart disease.

NCSHP staff say their own analysis of current research found there were “no studies that show a positive return on investment.”

It’s unclear whether the decision to end coverage will pressure manufacturers to budge on prices. Lester said on Tuesday that officials in the treasurer’s office “remain hopeful that the manufacturers will decide to put patients over profits, but as of yet we have not heard from them.”

Nicole Ferreira, a spokesperson for Novo Nordisk, told The N&O on Tuesday that while the company “strongly opposes creating new hurdles for patient access to care, we have and will continue to engage with NCSHP officials to address any potential cost concerns.”

What are other states doing?

The health insurance plan for University of Michigan employees announced earlier last year that it would raise copays for the drugs in order to incentivize members to pick cheaper, although less effective, medications instead.

The plan for University of Texas employees removed coverage for Wegovy and Saxenda on Sept. 1, citing “unsustainable costs” without a meaningful reduction in health care spending from obesity complications.

Last summer, Connecticut’s state health plan announced it would only cover weight-loss prescriptions written by doctors from a single, approved obesity treatment company.

Several other state health plans still maintain coverage of these obesity medications.

Will coverage of diabetes drugs be impacted by this change?

No.

Even though medications like Ozempic are very similar to Wegovy and Saxenda, coverage will not change for drugs prescribed for diabetes.

What about other weight-loss drugs?

The board’s decision also does not impact the coverage of other types of weight-loss drugs, including Phentermine, Adipex-P, Orlistat, Qsymia, Benzphetamine, Diethylpropion, and Phendimetrazine.

NC Reality Check is an N&O series holding those in power accountable and shining a light on public issues that affect the Triangle or North Carolina. Have a suggestion for a future story? Email realitycheck@newsobserver.com

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