NC State Health Plan begins crackdown on spending for weight-loss drugs
The North Carolina State Health Plan will put new measures in place to prevent diabetes drugs like Ozempic from being used off-label for weight loss, leadership announced at a meeting Wednesday night.
This is the plan’s first effort to rein in spending on a class of drugs called GLP-1s, which has put the plan’s finances “under siege.”
This group of drugs first made headlines in 2017, when the pharmaceutical company Novo Nordisk received approval for Ozempic to treat Type 2 diabetes. The popularity of these drugs grew after the Danish company received FDA approval in 2021 to market the same active ingredient at a different dose for weight loss, under the name brand Wegovy.
Among state health plan members, demand for these weight loss drugs skyrocketed from just a few thousand in 2021 to more than 23,000 this year.
Thousands of state health plan members who do not have diabetes are using drugs like Ozempic off-label to lose weight, a practice discouraged by the manufacturers but common in the United States.
New changes to the diabetes drug approval process — which will go into effect at the start of next year— will tamp down on off-label uses.
NCSHP tightens approval process for diabetes drugs
In August 2022, the state health plan began requiring doctors to prove their patients qualified for diabetes medications before covering drugs like Ozempic.
But representatives from CVS Caremark, the plan’s pharmacy benefit manager, said there was a “loophole” that allowed members to use the diabetes drugs for weight loss: A prior GLP-1 prescription automatically qualified them for more diabetes medications.
That meant if a member was using diabetes medications for weight loss before new approval requirements went into effect in August, they were automatically approved for more refills of the costly medications afterward — even if they didn’t have diabetes.
Plan leaders feared this loophole would be further exploited once the State Health Plan began covering Mounjaro, a new GLP-1 competitor to Ozempic that has been shown to cause even more dramatic weight loss.
NCSHP leadership voted to close that loophole Wednesday night, in order to “safeguard against inappropriate or off-label uses.”
New rules hold more significance with weight-loss drug coverage in limbo
Currently, the state health plan covers GLP-1s like Wegovy for weight loss, giving members access to the medication even if they do not have diabetes.
But recently, plan leaders have indicated that the coverage for weight loss GLP-1s might be in jeopardy.
State Treasurer Dale Folwell, who oversees the State Health Plan, said spending on this class of weight loss drugs has spiraled out of control. 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.
“We have no choice but to do what’s in the best interest of our members,” Folwell said. “And if that includes taking advice and best practices from other states … then we will do that.”
Folwell pointed to other plans that have restricted coverage of these drugs. The plan for University of Texas employees, for example, ended coverage for Wegovy and Saxenda on Sept. 1, citing “unsustainable costs.”
State Health Plan leaders are expected to discuss the future coverage of these weight loss drugs at the next Board of Trustees meeting on Oct. 26
Teddy Rosenbluth covers science and health care for The News & Observer in a position funded by Duke Health and the Burroughs Wellcome Fund. The N&O maintains full editorial control of the work.
This story was originally published October 12, 2023 at 3:51 PM with the headline "NC State Health Plan begins crackdown on spending for weight-loss drugs."
