On Jan. 1, North Dakota became the first state in the country where access to drugs like Wegovy is part of the EHB package.

About 55,293 of North Dakota's 784,000 residents had coverage through fully insured small-group health insurance plans in 2021, according to KFF.

ICHRA enrollment estimates are not available.

What it means: North Dakota employers may show what adding coverage for drugs like Wegovy for morbid obesity does to a plan's obesity drug costs, the health of the plan's enrollees and the plan's overall costs.

Essential health benefits: Drafters of the two 2010 laws that make up the Affordable Care Act created the EHB package system as part of the effort to help consumers shop for health coverage on the web and use federal premium tax credit subsidies to pay for the coverage.

Requiring a health insurer to cover the EHB package was part of the effort to make sure that the insurance purchased through ACA programs is good insurance. The EHB package includes services such as primary care, hospital care and wellness care.

The ACA requires individual major medical insurance policies and fully insured small-group plans to cover at least about 60% of the value of the items in the EHB package.

Employers with self-insured health plans or large, fully insured plans need not cover the EHB package, but, if they do offer any of the items in the EHB package, they cannot impose annual or lifetime limits on coverage for those EHBs.

What North Dakota did: In 2023, the North Dakota legislature approved a law that based the state's updated EHB package on the benefits provided by the North Dakota Public Employees Retirement System's grandfathered preferred provider organization plan for 2017.

The plan includes coverage for up to 12 nutritional counseling visits per year, and the legislature added access to GLP-1 agonists and GIP agonists to the nutritional counseling benefits package for state employees.

How it works: Because of the way the essential health benefits package rules work, the North Dakota update affects only fully insured small-group health insurance plans and individual policies, including individual policies workers buy using cash provided by their employers through IHCRAs.

Wegovy is a brand name for a drug that based on semaglutide, a "glucagon-like peptide-1 receptor agonist." A GLP-1 agonist is a molecule that can suppress a patient's appetite by mimicking a hormone that indicates that the patient has eaten.

Zepbound is a brand name for a drug based on tirzepatide, a drug that includes both a GLP-1 agonist and a "gastric inhibitory polypeptide agonist." A GIP agonist promotes weight loss by affecting the amount of insulin in a patient's blood.

The full list price for the new-generation weight-loss drugs is now about $17,000 per year for Wegovy and about $12,000 per year for Zepbound, according to GoodRx data.

UnitedHealth's UnitedHealthcare unit says it will cover either Wegovy or Zepbound for a patient with a body mass index of at least 40.0. About 9.2% of U.S. adults have a body mass index over 40, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

To get coverage for Wegovy, a patient must be at least 12 years old. To get Zepbound, a patient must be at least 16. The patient must use the drug together with a diet, exercise and counseling.

UnitedHealthcare will cover Wegovy, but not Zepbound, for patients using the drug to control diabetes, insulin resistance or metabolic syndrome using similar rules.

One question is what UnitedHealthcare and other payers will really end up paying for the drugs involved.

Companies like Novo Nordisk, the maker of Wegovy, have argued that Wegovy should be available to all patients who qualify for access to the drug under U.S. Food and Drug Administration guidelines. It has moved to withhold rebates from some employers, including a North Carolina employer plan, when the employers have limited access to Wegovy to certain classes of patients or required plan participants to try other weight-loss strategies before taking Wegovy.