Blue Cross Blue Shield of Michigan has announced it will stop covering certain weight-loss drugs for large groups of fully insured members starting January 1, 2025, as reported by CBS News Detroit. Corresponding changes in prior authorization for specific drugs like Saxenda, Wegovy, and Zepbound will take effect earlier, on August 1, 2024. The insurer underlined that the decision was the result of "careful consideration" of these medications' efficacy, access, safety, and cost implications.
BCBS Michigan, serving nearly 800,000 people in its large-group commercial plan, reportedly spent $1.8 billion more on pharmaceuticals in 2023 compared to previous years. Within this increase, expenses for GLP-1 weight-loss drugs surged by $350 million, per the information shared with Beckerspayer. Drugs in this category can cost patients upwards of $15,000 annually, raising concerns about their long-term affordability for the health system.
The insurer's chief medical officer, Dr. James Grant, communicated concerns regarding the drugs' affordability, “We didn’t make this decision lightly. There was a lot of discussion, a lot of analysis, to come to this conclusion.” In a move aligning with other insurers in the state, the exclusion of these drugs from coverage is said to help manage the spiraling costs, which are expected to reach near $200 million by 2025. The average list price for a drug like semaglutide, better known as Wegovy, exceeds $1,000 per month, Grant detailed to Bridge Michigan.
Further complicating the issue, data from the Blue Cross Blue Shield Association indicates a lack of perseverance among patients using GLP-1s for weight loss, with nearly 6 in 10 discontinuing use before realizing significant clinical benefits. Addressing the medication's effects on overall health outcomes, Hanna Jaworski, medical director of Pediatric Health Optimization Services at Helen DeVos Children’s Hospital, stressed the importance of evaluating reduced risks of serious conditions like Type 2 diabetes, heart attacks, and strokes. Despite the coverage shift, Michigan remains among 16 states that cover weight-loss drugs under Medicaid programs for both weight management and Type 2 diabetes management, according to Bridge Michigan.
As insurance companies and health care providers navigate the delicate balance between treatment efficacy, member needs, and economic sustainability, decisions like BCBS Michigan's undoubtedly have far-reaching implications for thousands of patients. This evolving landscape underscores a broader debate over the cost of pharmaceuticals and the allocation of healthcare resources.
