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TOPLINE:

Medicaid enrollees with type 2 diabetes (T2D) continue to face restricted access to newer cardioprotective diabetes medications — sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 receptor agonists (GLP-1 RAs) — despite recommendations as first-line treatment those also at risk for cardiovascular disease.

METHODOLOGY:

• For adults with T2D, studies suggest a large gap between guideline-based eligibility and actual use of newer cardioprotective diabetes drugs, a gap that may be even larger for Medicaid enrollees, possibly due to drug formulary policies that seek to reduce costs.
• Researchers conducted a nationwide cross-sectional study of Medicaid formulary policies to assess enrollees’ unrestricted access to SGLT2 inhibitors and GLP-1 RAs, as well as tirzepatide (a dual GLP-1 RA and glucose-dependent insulinotropic polypeptide RA).
• They used publicly available Medicaid formularies for Medicaid fee-for-service (FFS) plans from all US states (excluding Hawaii and including Washington, DC) and 273 adult managed care organizations (MCO) plans in 39 states as of March 2024.
• Data sources included Fingertip Formulary for plan-level formulary coverage and enrollment size, as well as the Centers for Disease Control and Prevention for the most recent state-level T2D prevalence and mortality to estimate T2D burden. Medicaid quality measures were obtained from the Centers for Medicare & Medicaid Services.
• The primary outcome was unrestricted availability of SGLT2 inhibitors and GLP-1 RAs, defined as the inclusion of at least one medication on the preferred drug list without prior authorization or step therapy; the availability of at least one dipeptidyl peptidase 4 (DPP-4) inhibitor was used as a benchmark because they are also expensive but lack the cardioprotective mortality benefits.

TAKEAWAY:

• Overall, an estimated 25% of Medicaid enrollees with T2D had restricted availability of a SGLT2 inhibitor, and 40% had restricted availability of a GLP-1 RA. Tirzepatide, a dual GLP-1 and glucose-dependent insulinotropic polypeptide RA, with potentially greater benefits, was almost entirely restricted nationwide. DPP-4 inhibitors had the greatest availability.
• The availability of SGLT2 inhibitors and GLP-1 RAs varied widely between states, from restricted for all enrollees to available for all. The availability of these medications has been increasing in recent years in FFS plans but appears to have plateaued in MCO plans, particularly for GLP-1 RAs.
• Overall, 80% of the FFS plans had unrestricted availability of SGLT2 inhibitors and 60% had unrestricted availability of GLP-1 RAs, with an 84% benchmark for the availability of DPP-4 inhibitors. The most common restriction was prior authorization. States with restricted coverage had more enrollees with diabetes and diabetes complications.
• MCO plans (which cover 80% of Medicaid enrollees) showed lower availability, with 66.7% offering SGLT2 inhibitors and 48% offering GLP-1 RAs without restrictions. The proportions of MCO enrollees with access to SGLT2 inhibitors and GLP-1 RAs varied widely across states, with some having full availability and others having limited access.

IN PRACTICE:

“Our findings call attention to the need to continue monitoring unrestricted availability for these medications in Medicaid, particularly for tirzepatide (which remains almost entirely restricted as of 2024) given its superior effectiveness among GLP-1 RA medications and expanding clinical indications,” the authors wrote. “Formulary plan coverage is a potential lever to mitigate health inequities for low-income Medicaid enrollees with diabetes, warranting consideration of state policy changes to increase access to these medications while balancing pharmaceutical costs,” they added.

SOURCE:

This study was led by Anil N. Makam, MD, MAS, Division of Hospital Medicine, University of California San Francisco. It was published online on April 22, 2025, in Annals of Internal Medicine.

LIMITATIONS:

Diabetes enrollment was estimated using plan size and state and national prevalence data. Current formulary coverage may differ from that in March 2024, as plans frequently update restrictions based on cost and usage. Plan-level data on diabetes prevalence was lacking. The absence of detailed information on prior authorization criteria, frequency of requests, and appeal processes may have limited the understanding of access challenges.

DISCLOSURES:

This study was supported by a UCSF Action Research Center for Health Equity Pilot Award. One author reported grant/contract from Action Research Center for Health Equity and gift from Chan Zuckerberg Biohub.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.