State-level variation in the use of glucagon-like peptide-1 receptor agonists for weight loss and diabetes: a real-world analysis

BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have demonstrated clinical benefits beyond glycemic control, including weight loss and cardiovascular protection. Given the growing interest in the clinical value of GLP-1 RAs, greater understanding of geographic variation in utilization by disease prevalence and the influence of state-level coverage policies is desirable. OBJECTIVE: To assess (1) state-level utilization of GLP-1 RAs by indication for diabetes and obesity, (2) correlation of those rates to the state-level prevalence of diabetes and obesity, and (3) state-specific Medicaid formulary coverage of GLP-1 RAs for weight loss and diabetes. METHODS: We conducted a cross-sectional analysis of pharmacy claims from the Komodo Healthcare Map between January 1 and December 31, 2023. GLP-1 RA utilization was defined as the prevalence of members with GLP-1 RA claims for US Food and Drug Administration-approved indications for diabetes or obesity. State-level diabetes and obesity prevalence were obtained from the 2022-2023 Behavioral Risk Factor Surveillance System. Medicaid coverage for GLP-1 RAs was categorized as "not covered," "restricted," or "unrestricted." Pearson correlation coefficients were calculated to assess relationships between state-level disease prevalence and GLP-1 RA utilization. RESULTS: State-level utilization of GLP-1 RAs for diabetes was strongly correlated with diabetes prevalence in the commercially insured population, but correlation was moderate with those with Medicare and weak with the Medicaid population. For obesity, utilization showed only weak or negligible correlations with obesity prevalence. Medicaid coverage policies influenced access where utilization in states with "restricted" or "unrestricted" coverage was nominally higher than in states with "not covered" policies. CONCLUSIONS: GLP-1 RA utilization in the United States varies substantially by payer type, indication, and state-level coverage policies.