A quite new group of medicines used for weight reduction has emerged, offering new alternatives for weight problems remedy but in addition elevating questions on access to and affordability of those medication. To start with authorised to regard sort 2 diabetes, those medication, referred to as GLP-1 (glucagon-like peptide-1) agonists, together with Novo Nordisk’s Ozempic, Rybelsus, and Wegovy (semaglutide) and Eli Lilly’s Mounjaro (tirzepatide), also are extremely efficient weight-loss brokers. Those medication are expensive when bought out of pocket, and Medicaid protection of those medication when used for weight reduction is these days limited, regardless that some states are taking steps to amplify protection. This temporary discusses Medicaid protection of weight-loss medication, fresh tendencies in Medicaid usage and gross spending on new medication used for weight reduction, and the possible implications of the ones new medication for Medicaid techniques and enrollees.
Does Medicaid duvet medication used for weight reduction?
States can make a decision whether or not to hide weight-loss medication below Medicaid, resulting in variation in protection insurance policies throughout states. Beneath the Medicaid Drug Rebate Program, Medicaid techniques will have to duvet the vast majority of a collaborating producer’s Meals and Drug Management (FDA)-approved medication for medically permitted indications. Alternatively, weight-loss medication are integrated in a small crew of gear that can be excluded from protection, and thus, some states don’t duvet weight-loss medication in Medicaid. Whilst a contemporary survey discovered various states had been bearing in mind including Medicaid protection of weight-loss medication, studies have proven a restricted choice of states duvet weight-loss medication in Medicaid, with some states handiest protecting the medicine for critical weight problems, with a comorbidity, or different restrictions. When prescribed by way of a health care provider, weight-loss medicines must be covered for kids below Medicaid’s Early and Periodic Screening, Diagnostic, and Remedy (EPSDT) program. Whilst state protection of weight-loss medication in Medicaid is proscribed, maximum GLP-1 agonists are authorised to regard sort 2 diabetes (Desk 1) and could be coated by way of Medicaid for remedy of sort 2 diabetes.
How has Medicaid usage and gross spending on new medication used for weight reduction modified lately?
Medicaid usage and gross spending on new medication used for weight reduction (GLP-1 agonists) have each greater unexpectedly lately, just about doubling each and every yr since 2019 (Determine 1). From 2019 to 2022, the choice of GLP-1 agonist prescriptions greater over 600%, whilst spending consistent with prescription greater 23%. Mirroring other KFF analysis, the price of each and every of those medication prior to rebates used to be over $900 consistent with prescription by way of 2022. The ones costs and spending numbers don’t account for rebates, and states are most probably receiving really extensive rebates on those emblem medication—Medicaid and CHIP Cost and Get admission to Fee (MACPAC) analysis of FY 2020 knowledge discovered statutory rebates had been round 61.6% of gross spending on emblem medication. GLP-1 agonists nonetheless account for small stocks of the entire choice of Medicaid prescriptions and spending prior to rebates, regardless that the stocks are rising. By way of 2022, those medication accounted for 0.2% of all Medicaid prescriptions (up from 0.02% in 2019) and 1.3% of all gross Medicaid spending (up from 0.2% in 2019).
In particular, greater usage of Ozempic has contributed considerably to fresh tendencies, most probably as it used to be the primary drug of this magnificence to obtain FDA approval. Ozempic used to be approved to lend a hand keep watch over blood sugar ranges for adults with sort 2 diabetes in 2017, adopted by way of Rybelsus in 2019, and Mounjaro in 2022 (Desk 1). Wegovy is the one GLP-1 agonist these days authorised for power weight control and used to be authorised for adults in 2021 and for kids ages 12 and up in 2022. State Medicaid protection of gear authorised for weight-loss (Wegovy on this research) is proscribed. Ozempic, Rybelsus, and Mounjaro are authorised to regard sort 2 diabetes and coated by way of Medicaid for that label indication, regardless that they’re additionally repeatedly prescribed off-label for weight reduction, together with for folks with different comparable chance elements. From Medicaid knowledge publicly to be had, there is not any manner but to disentangle how a lot of the rising use of those medication is said to remedy for diabetes as opposed to weight problems, or a mix of each.
What to observe having a look forward?
Increasing protection of weight-loss medication below Medicaid may build up get right of entry to to these medicines for folks with Medicaid. Nearly one-third of U.S. adults had weight problems in 2021, and with out insurance plans, new weight-loss medicines most probably stay unaffordable and inaccessible for plenty of folks, and particularly for Medicaid enrollees, who’re low source of revenue. KFF polling discovered about half of adults within the U.S. could be concerned about taking prescription weight-loss medication, regardless that passion drops if the drug isn’t coated by way of insurance coverage or after listening to sufferers may achieve weight again after preventing use. Some states are beginning to take steps to amplify protection of weight problems remedy together with prescribed drugs below Medicaid, and expanded protection would possibly lend a hand folks find the money for the medicines and deal with some disparities in get right of entry to. To the level that get right of entry to to medicines reduces weight problems charges amongst Medicaid enrollees, there may be longer-term discounts in Medicaid spending on chronic diseases related to weight problems, equivalent to center illness, sort 2 diabetes, and varieties of most cancers.
Alternatively, the brand new medicines do come with some side effects, and increasing protection of weight-loss medication in Medicaid will most probably result in additional will increase in Medicaid usage and spending. Research have additionally proven folks can regain the load in the event that they prevent taking the medicines, suggesting the medicine would possibly wish to be taken long run and extra impacting usage and spending tendencies. New American Academy of Pediatrics (AAPs) tips additionally now recommend pharmacotherapy weight problems remedy in youngsters ages 12 and older, and adjustments in physicians’ observe stemming from the up to date remedy suggestions may have a large impact on Medicaid techniques and enrollees as a result of Medicaid covers such a lot of youngsters. Finally, weight problems is brought about by way of a multitude of complicated elements, and uptake of latest weight-loss medication may enhance well being, however would no longer deal with the entire underlying members to weight problems.