NC coverage of obesity drugs ends April 1. Here are alternatives.

The NC State Health Plan’s coverage of popular obesity medications ends in one week, affecting thousands of public employees using them.

Some may be looking for alternatives to these medications. We’ve pulled together a guide explaining what weight-loss drugs remain covered, and more.

Wegovy out, but Ozempic is covered

Starting on April 1, the drugs no longer covered are Wegovy, Saxenda and Zepbound.

Those injectable obesity drugs are known as glucagon-like peptide 1 agonists, or GLP-1s. Novo Nordisk, a Danish company, manufactures Wegovy and Saxenda — as well as Ozempic, which is also a GLP-1 but is used for diabetes. Ozempic remains covered under the plan.

Zepbound, which was approved by the Food and Drug Administration in November for weight loss, is manufactured by Eli Lilly, a U.S. company. Mounjaro is the same drug as Zepbound but is prescribed for diabetes, and remains covered under the plan.

Besides those three drugs being excluded, the health plan won’t cover any new GLP-1s that may be approved in the future for weight loss by the FDA.

How effective are they?

GLP-1s exploded in popularity in recent years following the FDA approval of their use for people with obesity who do not have diabetes. These drugs help people stay full for a longer time and can help people lose over 10% of their body weight.

One study found 63% of participants who took Saxenda lost at least 5% of their body weight. About 33% lost at least 10% of their body weight.

A study on Wegovy found that 86% of people who took it lost at least 5% of their body weight. About 70% of users lost at least 10% of their body weight.

The average weight loss seen with medications that are not GLP-1s is about 5% to 9%, while those engaged in an active lifestyle without taking medication lose about 3% to 5% of their body weight, according to Harvard Health.

GLP-1 drugs are recommended for long-term use, as stopping may lead to gaining lost weight back. Common side effects can include nausea, constipation and low blood sugar.

But these blockbuster drugs came with a hefty price tag for the State Health Plan last year, with the plan paying about $550 for every Novo Nordisk prescription, after rebates. Citing unsustainable costs, the plan’s board of trustees in January voted to exclude coverage, including for those already taking the medication.

Asked for an update on negotiations, SHP spokesman Frank Lester said in an email that plan officials are still in negotiations with Novo Nordisk and pharmacy benefit manager CVS Caremark, “and remain hopeful.”

CVS Caremark serves as a middleman in negotiations between the state and drug manufacturers. Dan Knecht, vice president and chief clinical innovation officer at CVS Caremark, said the company is “doing everything in our power to bring solutions to our client, the State Health Plan,” and “have provided the State Health Plan with other coverage options for their consideration.”

Anti-obesity drugs: What’s covered?

Aside from drugs prescribed for diabetes that are still covered, a slew of other weight-loss drugs also remain covered.

Let’s take a look at these drugs, what they cost and how they work.

The State Health Plan covers at least one medication in two classes of weight-loss drugs: anorexiants, which are drugs that act on the brain to suppress appetite, and anti-obesity agents.

In terms of anti-obesity agents, the plan will now only cover generic orlistat.

Orlistat works by preventing some of the fat in foods eaten from being absorbed. The most common side effect is changes in bowel movements. A study found orlistat combined with diet and exercise helped people lose almost twice as much weight than without it.

Members of the State Health Plan can opt for the 70/30 PPO Plan, the 80/20 PPO Plan or the High Deductible Health Plan, all managed by CVS Caremark.

A 30-day supply of orlistat costs members on the 80/20 plan a $30 copay, and costs them a $47 copay on the 70/30 plan, said Lester. A copay is a flat fee that you pay for certain prescriptions.

Members on the HDHP pay half the cost of drugs while the state pays the other half, so costs under this plan vary with the pricing of the drug.

Orlistat requires prior authorization (meaning health care providers must obtain advance approval from CVS Caremark) for members to use. Without prior authorization, members’ costs for these drugs could go up.

Anti-obesity drugs that aren’t covered

Xenical, a brand of orlistat, is not covered, nor are Contrave and Imcivree.

Imcivree is only approved by the FDA to treat obesity caused by certain rare genetic conditions.

Contrave is used for long-term treatment for weight management. Clinical trials have shown the medication to be effective for many for at least a 5% weight loss.

Lester said Contrave is under review by the plan.

Lester said all coverage decisions are recommended by the PBM to the plan. The plan then decides whether to implement these recommendations. He said in an email that when certain drugs are not covered, it’s typically because of efforts by the PBM to lower plan costs.

Knecht said CVS Caremark is compensated by the State Health Plan via an administrative fee and does not make any additional compensation based on what drugs are covered. He said CVS passes “through 100 percent of any manufacturer rebates to the State Health Plan.”

Members who want to obtain a drug that is not covered but that shows up on the formulary, a list of certain covered and noncovered drugs, can request an exception.

Drugs that do not show up on the formulary (such as Wegovy and Saxenda) follow a benefit exclusion by the plan’s board of trustees. To apply for coverage of these drugs, plan members go through a separate medical necessity process rather than the exception process, Lester said.

Anorexiants covered in 2024

Anorexiants work by lowering the appetite, leading to less calorie consumption and in turn, weight loss.

They are controlled substances and are approved for short-term use, though some doctors may prescribe them longer off-label. All require a prior authorization.

Most of these drugs, alongside diet and exercise, have been shown to help reduce weight by at least 5% and at times more. They have varying side effects.

Drugs covered in this category are phentermine, Adipex-P (a brand of phentermine), Qsymia, phendimetrazine tartrate, diethylpropion and benzphetamine. Lomaira, also a brand of phentermine, is not covered under the plan.

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