Officials say the state’s Medicaid program hasn’t been covering certain weight loss drugs, despite a state law passed last year that requires it to do so.
In 2023, the legislature expanded Medicaid coverage to include obesity treatment services including bariatric surgery, nutritional counseling and drugs, like Wegovy, that have been approved by the U.S. Food and Drug Administration for weight loss. Despite the mandate, the Connecticut Department of Social Services has not been covering weight loss drugs because of cost concerns, said Sen. Matt Lesser, D-Middletown, one of the legislators who worked on the bill.
“It is discouraging when we work with DSS and the administration to pass a law and then they decide that the law doesn’t apply to them,” Lesser said.
In an emailed response to questions, Christine Stuart, a spokesperson for DSS, didn’t clarify whether or not the agency is covering FDA-approved weight loss drugs for Medicaid enrollees and, if not, whether that violates state law.
“Obesity is a complex and chronic medical condition that requires comprehensive, evidence-based management,” Stuart wrote. “We are dedicated to ensuring access to approved weight loss medications while maintaining thoughtful clinical oversight to safeguard Medicaid members’ long-term health and ensure coverage for those who meet the eligibility criteria.”
Connecticut guarantees coverage of weight loss drugs and nutritional counseling for Medicaid enrollees with a body mass index, or BMI, of at least 35. It also covers bariatric surgery for anyone with severe obesity — defined in the statute as a BMI of 35 or more with another condition or a BMI of 40 or above.
Under the legislation, the agency only has to cover drugs approved by the FDA for weight loss, like Wegovy. Ozempic, on the other hand, has only been approved for treating Type 2 diabetes, so the agency wouldn’t have to cover it for weight loss.
Some providers have been prescribing drugs like Ozempic to Medicaid enrollees for purposes other than Type 2 diabetes, including weight loss. But that practice will soon come to an end. Earlier this month, the agency issued a bulletin to medical providers and pharmacies saying Ozempic may now only be prescribed to patients with a Type 2 diabetes diagnosis. If the drug is currently prescribed for another purpose, DSS said it would no longer cover the cost after Jan. 15.
Now, Medicaid enrollees who use GLP-1 agonists for weight loss won’t have many options.
Lesser said officials at DSS confirmed to him that they’re not currently covering the cost of FDA-approved weight loss drugs or nutritional counseling. But he said they were less clear about whether bariatric surgeries are covered. He also said the agency doesn’t cover Wegovy for purposes other than weight loss, like the treatment of cardiovascular disease, which would violate federal law.
Drugs like Ozempic and Wegovy are part of a class of medications called glucagon-like peptide-1 agonists, or GLP-1 agonists, which mimic the GLP-1 hormone in the body that controls insulin and blood glucose levels. Their effects on the brain can also reduce hunger and help people feel full for longer.
The treatments, while expensive, have surged in popularity because of their effectiveness. In a recent study from the Yale School of Medicine, researchers concluded that the medications could prevent more than 40,000 deaths a year in the U.S.
“Expanding access to these medications is not just a matter of improving treatment options but also a crucial public health intervention,” stated Alison Galvani, one of the study’s authors.
Last month, the Biden administration proposed further expanding access to the drugs for enrollees in Medicare and Medicaid.
Currently, Connecticut is one of fewer than 20 states that covers a GLP-1 drug specifically for weight loss under the state’s Medicaid program. In a survey by KFF Health News, many states that don’t currently cover them indicated cost was a concern.
GLP-1 drugs come with a hefty price tag. Without insurance, they can cost as much as $1,000 a month. The high costs have led some insurers to roll back coverage, leaving people who have come to depend on them in limbo.
According to December estimates from Connecticut’s Office of Policy and Management, the state’s Medicaid program is on track to have a $260 million shortfall this fiscal year. Lesser said DSS told him cost concerns drove the decision not to cover weight loss drugs.
“What they have told me, and I believe them, is that when they first negotiated the law, they looked at the prices at the moment, and that the drug companies have since raised the price, and so that has changed the calculus,” he said.
Last week, Sheldon Toubman, an attorney with Disability Rights Connecticut, wrote a letter to DSS Commissioner Andrea Barton Reeves, calling on her agency to follow state and federal mandates.
“Apparently, your agency knowingly disregarded the law for a year and half [sic], and, when concerns were raised, agency employees were told that the law was not going to be implemented because of cost,” Toubman wrote.
Lesser said the state needs to look for creative ways to “strengthen” the agency’s negotiating position with drug manufacturers. Still, the high cost doesn’t give the agency permission to circumvent statute, he said.
“The cost of this coverage is quite high but that doesn’t mean flouting the law is ever acceptable,” he said.