Weight-loss drugs nixed from plan Weight-loss drugs Wegovy and Saxenda will no longer by covered by State Health Plan. Coverage to end April 1

The presentation included a list of the top-25 prescribers of weight loss drugs to State Health Plan members during 2023.

Triad and northwest North Carolina prescribers on the list are:

* No. 3: Daniel Watson, a pain-medicine specialist with Bethany Medical in Mount Airy. Wrote a total of 1,702 prescriptions for 145 patients, including a 555 prescriptions for 105 patients on weight-loss drugs.

* No. 4: Shannon Hall, a nurse practitioner with RestoreMD Med Spa in Elkin. Hall wrote a total of 2,244 prescriptions for 254 patients, including 609 prescriptions for 104 patients on weight-loss drugs.

* No. 11: Kelsey Anderson, physician assistant with Bariatric Solutions in Kernersville. Wrote a total of 474 prescriptions for 116 patients, including 289 prescriptions for 77 patients on weight-loss drugs.

* No. 23: Karen Bowen, obesity medicine specialist with Cone Health's Healthy Weight & Wellness in Greensboro. Wrote a total of 365 prescriptions for 95 patients, including 229 prescriptions for 61 patients on weight-loss drugs.

The top-25 list includes four medical professionals with Atrium Health in the Charlotte area and one with Novant Health Inc. in Salisbury.

The State Health Plan's Board of Trustees voted 4-3 on Thursday to end all insurance coverage of certain popular weight-loss drugs, such as Wegovy and Saxenda.

The decision means the 24,749 SHP members currently prescribed a GLP-1 drug for weight loss will lose their coverage on April 1. Those members represent about 3.3% of the nearly 750,000 SHP participants.

The board's Oct. 26 vote to halt new enrollments on Jan. 1, but allow existing patients to continue to get the drugs. That prompted about 1,500 members to enroll before the moratorium went into effect.

Sam Watts, the SHP''s interim director, said coverage will continue to diabetes drugs with a side benefit of weight loss, such as Ozempic, for diabetic patients.

Current participants can continue to be prescribed the GLP-1 drugs, but will either have to pay full price or obtain discount coupons from groups such as GoodRx.

The average age of a member using a weight-loss drug is 47, though the user range is listed as ages 12 to 83.

The SHP is North Carolina's largest purchaser of medical and pharmaceutical services and is self-funded. It covers teachers, state employees, legislators, retirees and their dependents. The state treasurer's office oversees the plan.

For many SHP members, including those who spoke Thursday and at the Oct. 26 meeting, weight-loss drugs have been a lifeline to a healthier life, with some reporting losing more than 100 pounds.

The board members who voted to end coverage shared state Treasurer Dale Folwell's concern that the increasing cost of the weight-loss drugs was becoming untenable for the plan.

"These are hard decisions," board member Wayne Fish said. "I've never liked the idea of cutting someone off cold turkey, but again, if we don't do something, where will this plan be in a couple of years?"

Folwell cited that the per-month cost of the drugs has risen from $3 million in 2020 ($36 million a year) to about $14 million in 2023 ($170 million a year) before manufacturer rebates. Those rebates reduced the SHP's cost to $102.2 million.

Ending new enrollments, but keeping the existing participants, was projected to reduce the fiscal 2024 cost to $139 million.

Before the Jan. 1 enrollment moratorium was approved, SHP staff had estimated a $50 million per-month cost, or $600 million, by 2029 before manufacturer rebates.

Public speakers stressed that exercise, gym memberships and diet aren't enough to fully assist many obese SHP members, and that dropping coverage is akin to discrimination against the obese.

Folwell has said he does not believe the SHP is trying to discriminate when it comes its consideration of dropping coverage of weight-loss drugs.

Board options

The SHP began covering weight-loss prescription drugs in January 2015 with Saxenda.

Wegovy was added in 2021. Drugs that treat diabetes, but have a side effect weight loss, such as Victoza and Ozempic, will contine to be covered for plan members with diabetes.

Wegovy, which contains the active ingredient semaglutide, is specifically approved for weight management.

Semaglutide imitates a hormone called glucagon-like peptide-1 (GLP-1), which prompts the body to produce more insulin and makes a person feel satiated, according to an Oct. 16 article in Scientific American.

People who take the drugs have had between 5% and 15% body weight reductions.

SHP staff presented the board with four options Thursday, none of which would have allowed for new enrollments. The others were:

* Maintaining the status quo of covering grandfathered participants.

* Maintaining the status quo of covering grandfathered participants, but have SHP staff continue to negotiate with drug manufacturers, in particular Novo Nordisk, and prescription benefit manager CVS Caremark for lower costs or higher rebates.

* End grandfathering of existing beneficiaries on April 1, but have SHP staff continue to negotiate with the drug manufacturers and pharmacy benefits manager CVS Caremark.

Staff said that discussions with CVS Caremark since the Oct. 26 meeting found that it would not approve continuing its benefits program, even for grandfathered participants, if enrollment was not restarted. CVS Caremark has previously said it would not approve limitations to its contract.

CVS Caremark also indicated it would withdraw rebates if the SHP began requiring members to meet certain health requirements to be covered, such as high body mass index score, or weight-related comorbid conditions, such as hypertension and Type 2 diabetes.

"It comes down to almost extortion to say, if you won't do this, we won't give you the rebate for your existing prescriptions," Fish said.

"That's like getting held up at gunpoint in a back alleyway."

Other health-related suggestions for eligibility approval included: requiring paying for an in-network nutritionist; completing a paid WellFrame weight-loss program; and completing a paid 15-week "eat smart, move more, weigh less" program

The presentation included marketing fliers from weight-loss providers that featured young adults or advertised "Mommy makeovers." Staff said that some prescribers didn't included a medical claim when submitting prescriptions.

Board members who voted to maintain the status quo emphasized the long-term benefit, both in overall member health and lower future coverage costs, from continuing to cover the weight-loss drugs.

"This is a life-saving drug, and we're talking about denying it," board member Dr. Melanie Bush said.

Some board members suggested that even with the 4-3 vote to end coverage that the reality of the coverage ending and the loss of SHP payments could prompt them back into negotiations.

"This will let (Novo Nordisk) know we're serious," board member Rusty Duke said. "Has anything changed since (Oct. 26 vote)? Nothing."

Novo Nordisk and CVS Caremark could not be immediately reached for comment Thursday on the board's decision.

In October, Novo Nordisk said in a statement that "we steadfastly oppose leaving patients without coverage, as this may have an overall effect on their health and wellness and may also prohibit healthcare practitioners from properly treating their patients who are living with obesity.

"The treasurer is keenly aware of how complex the prescription drug and health insurance system is, including the role of pharmacies, wholesalers, distributors and of course pharmacy benefit managers."

[email protected]@rcraverWSJ