State health plan shortfall points to challenge of expensive weight loss drugs

Boston Globe

21-05-2025

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Injectable GLP-1 drugs were initially developed to treat diabetes, then approved for obesity. Their popularity has risen among consumers eager to lose weight, and the drugs carry enormous potential health benefits in mitigating the risks of obesity-related disease. But they are expensive, with annual list prices as high as $16,000 and net prices, after discounts, of $7,000 to $9,000, according to
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Increased use of GLP-1 drugs was not the only factor in GIC's shortfall, but these medications have been causing GIC's costs to rise for years.
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According to
In the long term, drug prices may come down as more drugs enter the market and competition increases. Medicare will negotiate prices for some of these drugs to take effect in 2027. US consumers already pay more than Europeans for the same medication, and the ultimate solution will need to involve finding some way to lower prices for American consumers.
In the short-term, GIC is right to consider what solutions best balance cost and access. The main change announced so far is that beginning in July, CVS Caremark will 'prefer' the GLP-1 drug Wegovy. That means patients will no longer receive insurance coverage for another GLP-1 drug, Zepbound, unless they obtain an exception and pay a higher copay. The decision encouraged competition that enabled CVS Caremark to negotiate a lower price. CVS Caremark says its clients, including GIC, are expected to save 10 percent to 15 percent on their anti-obesity medicine costs.
It's a strategy similar to one used by MassHealth. In January,
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More changes for state employees' coverage may be forthcoming. GIC executive director Matthew Veno said at Thursday's meeting that GIC continues to be 'actively evaluating steps that we can take to strike the right balance between cost and access.' At a prior
Some other public plans are going further. North Carolina's state employee health plan last year
On the commercial market, Blue Cross Blue Shield Massachusetts
There is a benefit to giving employers choice in how much they want to pay for what coverage. The downside is when employees aren't covered, it creates inequality where only the wealthy can get drugs. Drugmakers now offer products directly to cash-paying consumers, with a year's supply of
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Compounded versions of the drugs also became available when these drugs were deemed to be in shortage in 2023 and 2024, and
Another important way to contain costs is to make sure patients who seek insurance coverage for GLP-1 drugs actually need them. But there isn't consensus on how to do this.
Some insurers require step therapy, first forcing patients to try a different drug or engage in a lifestyle management program. MassHealth requires members to try an oral appetite suppressant. But step therapy can potentially harm a patient — and make treatment longer and more expensive — if an insurer first requires a treatment not recommended by the patient's physician.
There is a need for clinical guidelines to determine when someone qualifies as obese. But the main clinical measure used is body mass index, which
Connecticut's state health insurance plan is experimenting with outsourcing obesity treatment to a third-party organization, FlyteHealth, which employs experts who prescribe GLP-1 and other drugs and use lifestyle management approaches. That model deserves more study to determine impacts on cost, care quality, and health outcomes.
There's no easy answer, but Massachusetts state officials deserve credit for trying to find ways to maintain coverage while cutting costs.
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