North Carolina renegotiates with CVS Caremark for the right to bargain directly on GLP-1s

North Carolina's State Health Plan has reached a new agreement with its pharmacy benefit manager, CVS Caremark, that lets the plan negotiate directly with GLP-1 manufacturers and offer coverage levels between full access and no access at all ^[1]. The change follows the plan's decision in April 2024 to stop covering GLP-1 medications for weight loss, a move that affected about 23,000 members who were using the drugs at a cost of more than $800 a month per person after rebates ^[1].

State Treasurer Brad Briner said the plan's earlier contract with CVS Caremark forced an all-or-nothing choice: either offer GLP-1s to every member for weight loss or offer them to none ^[1]. "There is an intermediate answer between those two extremes, but unfortunately the contract didn't permit it, so that's what we've negotiated," Briner said ^[1]. Health plan officials had projected that annual spending on the drugs would climb from about $170 million in 2024 to more than $1 billion by 2030 if coverage continued unchanged ^[1].

The drugs remain available to State Health Plan members who use them to treat diabetes; the exclusion applies only to weight-loss use ^[1]. Briner said the plan has begun "very preliminary" talks with manufacturers Novo Nordisk, which sells Ozempic and Wegovy, and Eli Lilly, which sells Mounjaro and Zepbound, now that direct negotiation is possible ^[1]. He described the early conversations as "promising," though still at an early stage ^[1].

Separately, the N.C. Senate had proposed $95 million in this year's state budget to cover GLP-1 medications for State Health Plan members with a body mass index of at least 38, but the House and Senate remain in a budget stalemate ^[1]. Briner said both a restored GLP-1 benefit and a broader weight management program are more likely to arrive in 2026 at the earliest ^[1].

Why it matters for patients

For the roughly 750,000 state workers, retirees, and family members covered by the North Carolina State Health Plan, this agreement does not immediately restore coverage for weight-loss GLP-1s ^[1]. It changes what the plan is contractually allowed to do, opening the door to a middle-ground benefit design rather than guaranteeing one. Members who currently pay out of pocket for Wegovy or Zepbound for weight loss will not see a change in their coverage from this announcement alone.

The plan is also weighing a broader weight management approach beyond medication. Briner pointed to AT&T's corporate program, which he called the "gold standard," as a model that includes regular check-ins with participants ^[1]. He said the goal is to "wrap people in a broad weight loss management program" alongside any GLP-1 benefit, rather than covering the drugs alone ^[1]. About 125,000 State Health Plan members are classified as obese, according to Briner ^[1].

The agreement also affects drug pricing more broadly. Briner said the rebate structure with CVS Caremark previously discouraged the use of Cordavis-made generic and biosimilar drugs, such as a version of Humira, because Caremark lost money when members used them instead of brand-name drugs ^[1]. The new contract changes that incentive, according to Briner: "If you're the branded pharma person, you're the loser in this conversation, but the PBM and particularly the State Health Plan are better off" ^[1].

What happens next

Briner said both the GLP-1 negotiation with manufacturers and the weight management program will likely not be finalized before 2026 ^[1]. The state budget stalemate over the proposed $95 million GLP-1 line item remains unresolved as of this report ^[1]. CVS Caremark's overall contract as the State Health Plan's pharmacy benefit manager runs through the end of 2027 ^[1]. No specific date has been set for when, or whether, GLP-1 coverage for weight loss will resume for State Health Plan members.