Written by Skylar Laird, SC Daily Gazette.
Starting in January, South Carolina’s Medicaid program will no longer cover weight loss drugs for obesity, reversing a year-old policy.
The change, which comes as states face high costs for covering the popular drugs, will not affect Medicaid patients prescribed the drugs to manage Type 2 diabetes, said Jeff Leieritz, spokesman for the state Department of Health and Human Services. Coverage to treat obesity will end Jan. 1, he said.
The class of medications called GLP-1 drugs mimic a hormone in the body’s intestinal track to balance blood sugar levels and send the brain a signal that reduces hunger, which an increasing number of people have used to lose weight.
On Nov. 1, 2024, South Carolina became the 14th state to cover the drugs for weight loss as well as diabetes, as long as patients met prior authorization requirements.
Ozempic is arguably the most well-known GLP-1 drug and often used off-label for weight loss. But the drug never received federal approval for that use. So, while the state’s Medicaid plan pays for Ozempic to treat diabetes, it never covered it for weight loss.
Instead, Medicaid covered Wegovy, Saxenda, or its generic version if patients’ body mass index qualified them as obese and they had related health problems. They also had to participate in dietary counseling, and their doctor needed to attest they were increasing their physical activity.
The change was part of a larger anti-obesity initiative in a state where 36% of all adults were considered obese in 2023, a higher rate than all but a dozen other states, according to the most recent data from the Centers for Disease Control and Prevention.
Medicaid officials expected the medications and dietary counseling to cost the state $3.3 million annually, Leieritz said previously.
But reimbursements for the drugs alone cost $2.3 million in state taxes, plus $5.5 million in federal taxes, for weight loss prescriptions in the last fiscal year, Leieritz said. And the policy change occurred four months into the year.
Leieritz did not immediately have available the price of the dietary counseling portion, which is billed separately.
The agency also did not provide an estimated cost of continuing to cover the drugs for weight loss.
The decision to stop covering weight loss drugs also followed a reversal in federal policy. The Trump administration earlier this year rejected a policy the Biden administration was considering that would have required every state to cover the cost of the drugs for obese patients.
The cost and federal policy change, along with the looming possibilities of an economic downturn and cuts in federal funding for state programs, likely led state leaders to make hard decisions about what they should cover, said Brad Wright, chair of health services policy and management at the University of South Carolina’s Arnold School of Public Health.
“You’re seeing states having to make these choices where they have to balance their budget,” Wright said. “It could be a real stressor on the budget for sure.”
As of Monday, the list price for Wegovy was $349 per month, a reduction from the previous list price of $1,350 per month. That followed President Donald Trump’s announcement he would negotiate with pharmaceutical companies to lower the prices of the drugs. States often receive rebates to further reduce prices.
The state Medicaid agency will consider those lower costs when deciding whether to add the medications back onto the state’s list of covered drugs in the future, Leieritz said.
North Carolina made a similar switch in coverage policy last month, citing the high cost of covering the medications for obesity. The drugs remain on the state’s list of approved prescriptions to treat heart disease and sleep apnea, according to the state’s Medicaid agency.
But the drugs aren’t without dangers of their own.
Common side effects of GLP-1 drugs include nausea, diarrhea, vomiting and dizziness. In more serious cases, the medication can cause low blood sugar, pancreatitis, kidney failure and thyroid tumors, according to websites for Wegovy and Ozempic.
In South Carolina, which is among 10 states that have not expanded Medicaid to all adults making 138% of the federal poverty level, the program covers low-income children and their parents, along with elderly and disabled people. Income requirements vary depending on the category a person falls into, but regardless, people who qualify for Medicaid generally can’t afford hundreds of dollars each month for weight loss drugs, said Ada Stewart, a Columbia-based family physician.
Low-income people are also often those who need the drugs most, she said. Healthy foods are typically pricier than less-nutritional-but-more-filling alternatives, and people struggling for money likely can’t afford a gym membership or don’t have the time or know-how to exercise, she said.
“It’s sad that we have medications that could work or could save lives and the individuals who could benefit the most can’t have access to this because of barriers that exist,” Stewart said. “If we could remove those barriers, we could have a healthier, more sustainable society.”
For patients who struggle to lose weight in other ways, the drugs can be a literal lifesaver, Stewart said. After losing significant amounts of weight, her patients who take the medications become less likely to have heart attacks or develop diabetes than they were before, she said.
Although removing the drugs from the coverage list will save the state money in the short-term, Stewart said she worried it will cost more in the long run as more people develop other health conditions related to obesity.
“I think that’s something we really need to think about more,” Stewart said. “It’s going to be a larger overall cost, a cost to the system.”
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