Payer Roundup–Molina Healthcare strengthens partnership with BeMe Health; North Carolina health plan limits GLP-1 coverage

Below is a roundup of payer-centric news for the week of Jan. 29, 2024.

UPDATED: Wednesday, January 31 at 10:10 ET

Molina Healthcare of Florida partners with teen behavioral health app

Molina Healthcare of Florida and BeMe Health, a mental health app for teens, are partnering to provide customized mental health activities and coaching to more than 22,000 in-network teenagers.

Data from the National Alliance on Mental Illness find that 180,000 adolescents aged 12 to 17 have depression, yet 64% received no care in the last year, according to a press release.

BeMe Health finalized partnerships with Molina Healthcare of California, Inland Empire Health Plan and Blue Cross and Blue Shield of Kansas, Fierce Healthcare reported in November. BeMe CEO Nicki Tessler said it disguises clinical interventions through fun, kid-friendly activities with a "medicine in honey" approach.

North Carolina State Health Plan cuts Wegovy coverage

Starting April 1, the North Carolina State Health Plan will stop covering GLP-1 drugs for weight loss, including Wegovy, The vote was a 4-3 decision in favor of phasing out coverage, but individuals can still be covered for a diabetes diagnosis.

Demand for GLP-1 drugs has steadily increased, leading to payers across the country to worry about the associated costs. At the beginning of 2023, the state's health plan covered 5,000 prescriptions for GLP-1 drugs, but that number skyrocketed to nearly 25,000 by the end of 2023. Local TV station WRAL said these members will keep their coverage, but new prescriptions will no longer be covered.

North Carolina Deputy Treasurer Frank Lester gave further context of the situation to Fierce Healthcare in an email Wednesday. He noted that GLP-1 prescription costs have jumped from $3 million a month three years ago to more than $14 million per month last year before rebates. For Wegovy and Saxenda, the price is more than $800 per member per month after rebates. And while GLP-1 medications were projected to cost the state plan more than $170 million this year, they expect it could surpass $1 billion over the next six years. 

State administrators worried the finances were no longer feasible for the state. Despite the state now paying $139 million for current prescriptions — more than the rebate offer from Novo Nordisk and pharmacy benefit manager CVS/Caremark that cost $85 million, due to Novo Nordisk suspending all rebates for members grandfathered in from the old policy as a result of North Carolina cutting coverage — the state is still paying less than the projected $170 million it would have spent to cover new prescriptions.

The North Carolina State Health Plan had covered GLP-1 drugs for weight loss since 2015, but it joins a growing movement of public employee health plans choosing to cut back on coverage. Lester said the health plan faces a $4.2 billion budget gap over the next five years, and that continuing to cover GLP-1 drugs for weight loss would result in "a premium increase of $48.50 per month for teachers and other state employees doubling the premium for individual subscribers."

In a new white paper released by Milliman, the consulting firm shows that GLP-1 drugs represented more than $4 billion in gross Medicaid spend in 2022, and utilization is expected to continue rising as more drugs enter the market. It's expected more use cases will be applied to GLP-1 agonists as more studies are conducted.

The paper suggests there may be an opening for state Medicaid programs to contract with manufacturers through value-based agreements to reduce costs. This would allow states to monitor patient outcomes including comorbidities.

Medical Mutual acquiring ProMedica's insurance brand

Paramount Health Insurance, the commercial and traditional Medicare insurance subsidiary of ProMedica, will be bought by Medical Mutual. The transaction is expected to close May 1.

The insurance line will still operate under the Paramount name, and all of ProMedica's providers will still be in network for members that transition over to Medical Mutual. ProMedica said it doesn't expect members' health insurance plans to change for the 2024 year in a FAQ post Monday.

ProMedica is a nonprofit health system in Toledo, Ohio, while Medical Mutual is a 90-year-old insurer and one of the largest in Ohio.