The board that oversees the North Carolina State Health Plan will face a heavy decision Thursday when it considers dropping coverage of weight loss medications like Wegovy.
Dropping coverage would affect more than 24,000 health plan members with existing prescriptions, including Jessica Uhrick-Rieger who started taking Wegovy when she gained weight after cutting back on daily running during the pandemic.
"I can remember in October of '22, I went for a general checkup and I couldn't believe that I had gained that much weight," Uhrick-Rieger said. "Because I was still eating like I ran five to eight miles a day, but I wasn't running five to eight miles a day."
That weight gain increased her body mass index to more than 30, and with it came commonly associated health problems.
"I had high blood pressure, I was pre-diabetic. I had a lot of anxiety and depression just over having to go back in person to work and having gained that much weight," she said.
When her doctor suggested Wegovy, the weight loss medicine that has gained international attention, she gave it a shot, and it worked. She lost 103 pounds over the course of about a year and brought her weight back down to about 124 pounds. And she’s no longer at risk for many of those weight-associated illnesses.
Now, however, Uhrick-Rieger faces a different problem. Wegovy, made by Danish drug company Novo Nordisk, is very expensive. She pays a $24.99 copay for the medication, and the State Health Plan pays the rest, which runs hundreds of dollars a month.
But because Wegovy — and similar medicines like Zepbound and Saxenda — come at such a high cost, the plan might soon drop coverage as a treatment for weight loss.
"If I were to have to suddenly stop taking it, would I then gain back all the weight that I had lost? Would I be able to maintain it," Uhrick-Rieger asked, rhetorically. "Not only from an appearance standpoint, but then from a health standpoint, too. I don't want to have high blood pressure."
Wegovy price has possibility of 'torpedoing' the State Health Plan
This class of medicine, called GLP-1, was initially approved by the Food and Drug Administration in 2005 to treat diabetes. Ozempic, for example, is a lower dose of Wegovy and still prescribed for Type-2 diabetes.
The State Health Plan is the health insurance plan for more than 740,000 teachers, state employees, retirees, and their dependents. It's a massive health plan that paid more than $4 billion in claims last fiscal year, according to plan data.
But even at that size, the high costs of these GLP-1 medications take an outsized bite of the pie. In 2023, the 24,750 people with prescriptions of Wegovy, Saxenda, and Zepbound cost the plan $102 million after rebates. In 2024, CVS Caremark, the plan's pharmacy benefits manager, warned those rebates might lessen or go away completely, something that could push total costs north of $170 million. For context, as recently as 2019-20, the plan paid less than $790 million for all pharmacy claims for the entire fiscal year.
The list prices per prescription refill for Wegovy and Saxenda, which come in four pre-filled pens that patients use to inject themselves, are $1,349 a month, according to the State Health Plan.
"This one drug has the potential of torpedoing the finances of the State Health Plan," said State Treasurer Dale Folwell, who is seeking the 2024 Republican nomination for governor.
In North Carolina, the state treasurer oversees the state health plan, while a board of trustees makes the final decisions. Already, the board has put a moratorium on new prescriptions of these medicines for weight loss and will consider dropping the benefit altogether, including for the nearly 25,000 people like Uhrick-Rieger with existing prescriptions.
"Because (neither) the manufacturer nor the pharmacy benefit manager who we contract with will work with us to get the cost down," said Folwell.
If the board decides to remove coverage, the benefit would end beginning April 1. These medicines would still be available to patients with Type-2 diabetes.
Ardis Watkins, president of the State Employees Association of North Carolina, supports the efforts to lower prices and keep the medicines available to state employees — but she’s not optimistic anything will change soon.
"It's a free for all," Watkins said. "We allow people to gauge our citizens as much as they want to. Our government and the politicians in this country have allowed this for ages, and so the drug companies are absolutely digging their heels in at the thought of any change."
Effective medicine with support from doctors
These medicines have become such a flash point in part because they're simply so effective. In mid-2021, the State Health Plan had just 2,795 users of a GLP-1 medication for weight loss. That figure has grown nearly nine times, including some 2,000 new users who filled a first prescription since Oct. 26, when the SHP board first considered dropping coverage and announced a moratorium on new prescriptions that began Jan. 1.
Dr. Andrea Coviello directs the UNC Weight Management Program and explains why this class of medicine works so well: "They're medications that are synthetic versions of some of your natural gut hormones. And I think that's why they were such a game changer."
Coviello commended the state health plan as one that has been forward thinking as it relates to weight loss treatments — and has covered weight loss medication and surgery for years.
And unlike most other employer-based health insurance, the state health plan covers retirees. Coviello said it therefore has more of a financial incentive to keep people healthy for their whole life, not just until they roll off the plan.
"With life expectancy in this country, which is fairly long, we want people to have good coverage for weight loss extending into their senior years," Coviello said.
If the State Health Plan Board continues to cover GLP-1 medications, the treasurer's office estimated that it would increase monthly premiums for everyone on the plan, not just users of the medication, by $48.50 per month. Coviello and other weight loss experts say prices could come down in three to five years as other drug manufacturers bring their own treatments to market.
For now, the price tag remains high.
