(13) Implications of Wegovy® utilization in the New York State Medicaid Program

Background: : Wegovy® is a semaglutide product approved by the Food and Drug Administration (FDA) in 2021 for weight loss and management in patients with obesity or overweight with ≥1 weight-related condition. In March 2024, the FDA approved Wegovy® for reduction in the risk of major adverse cardiovascular (CV) events in patients with obesity and overweight and established CV disease. A review of Wegovy® was presented to the New York State (NYS) Medicaid Drug Utilization Review Board (DURB) in October 2024 to implement coverage criteria aligned with the supplemental indication; coverage for weight loss alone is prohibited per NYS Code, Rules and Regulations.

Objective: : To evaluate the potential impact to NYS Medicaid of adding Wegovy® to the Medicaid List of Reimbursable Drugs.

Methods: : Retrospective analyses of pharmacy and medical claims were conducted for state fiscal year (SFY) 2024. Diagnoses were identified through International Classification of Diseases, 10th revision, codes and included overweight (body mass index [BMI] 25 to < 30 kg/m2), obesity (BMI ≥30 kg/m2), type 2 diabetes mellitus (T2DM), and CV conditions. Utilization of CV drugs was identified from pharmacy claims and included drugs reported in the Semaglutide Effects on Cardiovascular Outcomes in People with Overweight or Obesity (SELECT) trial. The analysis population was defined as members with overweight or obesity and CV disease, without a diagnosis of T2DM; members with T2DM were excluded due to qualification for the semaglutide product Ozempic®.

Results: : A total of 7.7 million members were enrolled in NYS Medicaid during SFY 2024. Of these, 1.26 million members had a diagnosis of overweight or obesity without T2DM. Over 85% were ≥18 years of age, 62% were male, and approximately 16% (n=200,000) had a diagnosis of CV disease. Specific BMI ranges were identifiable for 65% of these members; 22% had BMI 25 to < 30 kg/m2 and 43% had BMI ≥30 kg/m2. Among members with CV disease, 54% used drugs from ≥1 of the included classes, and 32% used drugs from ≥2 different classes. Approximately 46% of members had no claims for CV medications.

Conclusions: : Nearly 200,000 NYS Medicaid members had diagnosis codes aligned with the supplemental indication of Wegovy® during SFY 2024; however, almost half did not have claims for CV medications. Recommendations were made to the DURB to implement criteria including confirmation of overweight or obesity and CV disease, absence of T2DM, utilization of ≥1 CV medication in the past 30 days, no concurrent use of other semaglutide products, and dosing corresponding to the labeling.

Sponsorship:: New York State Department of Health