State Coverage and Reimbursement of Antiobesity Medications in Medicaid

Abstract

This study examines state Medicaid coverage policies for antiobesity medications and their trends in Medicaid reimbursement from 2011 to 2022.

Recently, glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have emerged as safe and effective treatments for obesity, with ability to improve long-term cardiovascular outcomes. However, their high cost has raised concerns about their budgetary effect, particularly for public insurance programs. Medicare Part D plans statutorily cannot cover antiobesity medications, but state Medicaid programs have more flexibility.¹ We examined state Medicaid coverage policies for antiobesity medications and their trends in Medicaid reimbursement from 2011 to 2022.

Methods

We identified antiobesity medications approved by the Food and Drug Administration through 2022: orlistat, lorcaserin, phentermine-topiramate, bupropion-naltrexone, liraglutide, and semaglutide.² For the 2 GLP-1 RAs (liraglutide, semaglutide), we focused on branded versions approved to treat obesity (Saxenda, Wegovy). We measured coverage of diabetes versions of these drugs (Victoza, Ozempic). Separate coverage policies existed for diabetes and antiobesity versions of these drugs; thus, diabetes versions might be used off-label to treat obesity. Coverage for each drug was determined from public state Medicaid formulary and preferred drug list files from the first quarter of 2023 (eTable in Supplement 1). Coverage was categorized as none, restricted (nonpreferred status or required prior authorization or step therapy), or unrestricted. We identified states with coverage for 1 or more antiobesity medications and those with unrestricted coverage for diabetes versions of GLP-1 RAs.

We obtained the quarterly number of reimbursed prescriptions for each antiobesity medication (excluding diabetes versions of GLP-1 RAs) from 2011-2022 from public Medicaid State Drug Utilization Data, which includes data from all 50 states. Data were stratified by reimbursement from fee-for-service (FFS) Medicaid vs managed care organizations (MCOs); although FFS reimbursement is directly related to state formularies, MCOs can have different coverage policies.³ Analyses were performed in Stata version 13.1 (StataCorp) and Excel version 16 (Microsoft).

Results

In the first quarter of 2023, 10 of 47 states (21%) with public preferred drug lists covered at least 1 antiobesity medication; 5 (11%) had unrestricted coverage of at least 1 antiobesity medication (Figure 1). Separately, 39 states (83%) had unrestricted coverage of at least 1 of the 2 diabetes versions of GLP-1 RAs.

Figure 1. Coverage of Antiobesity Medications in Medicaid States With Preferred Drug Lists in 2023^a.

^aNumber of states out of 47 states that had public formulary or preferred drug lists. GLP-1 indicates glucagon-like peptide 1; RA, receptor agonist.

The number of antiobesity medication prescriptions reimbursed by state Medicaid programs increased more than 1300%, from 7611 in 2011 to 108 525 in 2022 (Figure 2), owing to greater reimbursement of GLP-1 RAs. In 2022, 94 586 (87%) of 108 525 reimbursements for antiobesity medications were for liraglutide (Saxenda) or semaglutide (Wegovy). The number of states with documented reimbursements for antiobesity medications increased from 13 of 50 (26%) in 2011 to 22 (44%) in 2022, including 9 of the 10 states with publicized statewide coverage plus 13 additional states. Overall, 8 states reimbursed antiobesity medications via FFS Medicaid and 14 via MCOs.

Figure 2. Reimbursed Prescriptions for Antiobesity Medications in Medicaid, 2011-2022.

Discussion

As of early 2023, 1 in 5 state Medicaid programs covered antiobesity medications. Additional states covered these drugs through MCOs or had unrestricted coverage of GLP-1 RAs for diabetes that could be prescribed off-label for obesity management. The number of reimbursed prescriptions for antiobesity medications increased substantially from 2011 to 2022 owing to increased state coverage and use of GLP-1 RAs. This study was limited by inability to measure off-label use of diabetes versions of GLP-1 RAs for obesity management. Also, state formularies may have changed since early 2023 and additional weight management drugs have been approved since study completion.

Under the Medicaid Drug Rebate Program, states are required to cover nearly all approved medications, but Congress exempted antiobesity medications.⁴ With increasing evidence that GLP-1 RAs not only cause weight loss but also reduce complications from obesity like cardiovascular disease, state Medicaid programs face increasing pressure to cover these medications. In 2021, 40% of Medicaid enrollees had obesity.⁵ This prevalence, combined with high prices for GLP-1 RAs, raises budgetary concerns; ensuring access to these drugs for the vulnerable Medicaid population requires states or the federal government to negotiate lower prices.

Section Editors: Kristin Walter, MD, and Jody W. Zylke, MD, Deputy Editors; Karen Lasser, MD, Senior Editor.

Supplement 1.

eTable. Coverage of Anti-obesity Medications and GLP-1 Receptor Agonists on State Medicaid Unrestricted Drug Lists in the First Quarter of 2023

Supplement 2.

Data Sharing Statement