Weight Loss Medication Covered By Medicaid: A Guide

Finding affordable and effective weight loss solutions can be tough. Medicaid, a federal and state healthcare program, might cover some weight loss medications. This could be a ray of hope for those in need. In this guide, we’ll dive into Medicaid’s stance on weight loss drugs, the options available, and how to navigate this part of your healthcare.

• Medicaid coverage for weight loss drugs varies by state. Some states offer more coverage than others.
• GLP-1 medications like Saxenda, Wegovy, and Zepbound are known for weight loss. They might be covered by Medicaid in some states¹.
• You often need prior authorization for Medicaid to cover weight loss meds. Off-label or compounded GLP-1 drugs are rarely covered¹.
• In 2020, nearly 40% of Medicaid beneficiaries had obesity. This shows the need for better access to weight loss treatments¹.
• It’s key to know your state’s specific coverage and eligibility. This is crucial for getting Medicaid support for weight management.

Figuring out Medicaid coverage for weight loss meds can be tough. Medicaid usually covers most FDA-approved drugs, but weight loss meds are an exception². Each state decides if they will cover these drugs, so coverage varies a lot.

To get Medicaid to cover weight loss drugs, you must meet some rules. You usually need a Body Mass Index (BMI) of 30 or more. Or, if your BMI is 27 and you have health issues related to weight, you might qualify too³.

Children and teens have their own rules. They need a BMI in the 95th percentile and a weight-related health issue.

How much Medicaid covers weight loss meds varies by state. By July 1, 2024, 12 states said they would cover GLP-1 meds for obesity². But, each state has its own rules, like needing a doctor’s okay or meeting a BMI level.

Medicaid can choose which weight loss drugs to cover, but they must follow federal rules. Medicare Part D doesn’t cover weight loss meds, unlike Medicaid³. This means people with both Medicare and Medicaid might get weight loss drugs through Medicaid if Medicare says no.

As more people want to manage their weight, Medicaid’s rules for obesity meds are changing. It’s important for patients and doctors to understand the rules, state policies, and federal guidelines.

“The decision to cover obesity drugs ultimately lies with individual state Medicaid programs, leading to significant variations in the availability of these treatments across the country.”

Medicaid in the U.S. now covers many FDA-approved weight loss drugs for those who qualify. These include GLP-1 (Glucagon-Like Peptide-1) medications. They help with obesity and lower the risk of heart problems⁴.

Medicaid covers Saxenda (liraglutide), Wegovy (semaglutide), and Zepbound (tirzepatide) for weight loss⁵. It also covers other GLP-1 drugs for type 2 diabetes like Ozempic, Rybelsus, Victoza, and Mounjaro⁵.

Starting March 2024, Medicaid must cover Wegovy for adults with heart disease to prevent more heart issues⁵. All FDA-approved obesity drugs are also covered for kids under Medicaid’s EPSDT benefit⁴.

As obesity is seen as a serious chronic disease, Medicaid’s coverage for weight loss drugs is expanding. This gives more people access to effective treatments⁵.

Recently, the options for weight loss medications covered by Medicaid have grown. This includes Saxenda (approved in 2014), Wegovy (approved in 2021), and Zepbound (approved in 2023)⁶. These are all FDA-approved GLP-1 agonists for managing weight.

Saxenda, made by Novo Nordisk, is approved for chronic weight management. But, Medicaid coverage for Saxenda varies by state. Only 16 states currently cover it for weight management⁶.

Wegovy, also by Novo Nordisk, is another FDA-approved weight management drug. Like Saxenda, Medicaid coverage for Wegovy is limited. Only 13 state Medicaid programs cover it for obesity treatment⁷.

Zepbound, made by Eli Lilly, is the newest FDA-approved weight management drug. It helps people lose over 10% of their body weight⁸. However, its Medicaid coverage is still developing. States must create clinical criteria and get legislative approval to add it to their plans⁷.

Medicaid must cover FDA-approved drugs, except for weight management, cosmetic, and cough and cold medicines⁶. Medicare doesn’t cover drugs for obesity or weight loss⁶.

These GLP-1 medications are approved for weight management. But, Medicaid might cover them for other conditions like heart disease, even if not for weight loss⁶. Manufacturers are also looking into new uses, like sleep apnea and addiction treatment, which could affect Medicaid coverage⁶.

The availability and coverage of these medications under Medicaid are complex and changing. There are big differences in coverage across states, including eligibility and what’s needed for approval⁶⁷⁸.

Getting Medicaid to cover weight loss meds can be tough. Many states, like New York, list GLP-1 agonists as preferred drugs but need prior approval⁹. Non-preferred drugs in this group also need approval, and Medicaid might only cover one type or strength at a time⁹.

What’s covered can change from state to state. For example, Mississippi Medicaid covers certain weight loss drugs for kids 12 and up, but not Qsymia because of a lack of rebate¹⁰. They also have rules based on BMI and health conditions, and how long you can take the meds¹⁰.

Medicaid might give you a short-term supply of meds while they review your request¹¹. You might get a 72-hour or 7-day supply in some cases¹¹. They also might ask for proof, like taking other meds or trying a different drug first¹¹.

Healthcare providers need to know the Medicaid rules for weight loss meds⁹. It helps to reach out to Medicaid’s education team for help with the approval process⁹.

“Navigating the Medicaid prior authorization process for weight loss medications can be a challenge, but understanding the state-specific requirements and working closely with the program’s resources can help ensure patients receive the coverage they need.”

The demand for affordable weight loss medication is growing. The Medicaid Drug Rebate Program helps keep costs down for Medicaid programs¹². From 2019 to 2023, Medicaid spending on GLP-1s, a type of weight loss drug, jumped by over 500%¹².

Before rebates, each prescription cost over $900 in 2023¹². But, the Medicaid Drug Rebate Program has cut these costs. In FY 2020, rebates covered 61.6% of Medicaid spending on brand drugs¹³.

Pharmaceutical companies must give rebates to Medicaid agencies to help cover drug costs¹³. Novo Nordisk, the maker of Ozempic and Wegovy, says rebates and fees make up about 40% of the drugs’ costs¹².

Patients’ costs are capped by the Medicaid Drug Rebate Program¹³. Medicaid copays for non-preferred drugs, like some weight loss meds, are only $8 per prescription¹³. This ensures low-income people can get these treatments¹³.

More people are seeking low-cost obesity treatments on Medicaid, raising drug spending¹². In FY 2023, drugs make up about 6% of Medicaid spending, up from 4.6% in FY 2017¹². But, the Medicaid Drug Rebate Program and other measures help control costs¹³.

The Medicaid Drug Rebate Program is key in making weight loss treatments affordable for low-income people¹²¹³.

States are working hard to fight the growing obesity problem. Medicaid’s coverage for medicaid weight management medication and medicaid coverage for obesity medication changes a lot. Some states ask people to join exercise or limit how much medication they can get¹⁴. Others are looking to change how they cover obesity treatments to help more people¹⁴.

What decides if a state covers obesity treatments includes the cost, if laws need to change, and if people will stick to the treatment. Being overweight is linked to serious like diabetes and heart disease. This shows why Medicaid needs to cover obesity treatments well¹⁵.

As states work on their medicaid weight management medication and medicaid coverage for obesity medication rules, it’s key to fix these issues. This will help make sure everyone has fair access to treatments that work¹⁴.

By taking a full approach to fighting obesity, Medicaid can greatly improve the health of its members.

“Improving access to obesity treatments through Medicaid can lead to better health outcomes and reduced healthcare costs in the long run.”

Medicaid is now looking beyond just medication for weight management. Many states are adding lifestyle programs and nutritional counseling to their Medicaid benefits for weight loss¹⁶.

Medicaid programs are now covering intensive lifestyle modification programs. These programs offer dietary guidance, physical activity coaching, and behavioral therapy. They help participants achieve lasting weight loss¹⁷.

By focusing on the root causes of obesity, these programs aim to provide long-term solutions. They help Medicaid beneficiaries manage their weight in a more holistic way.

Medicaid also offers nutritional counseling as a preventive service or part of disease management programs. These “in lieu of services” give Medicaid beneficiaries access to registered dietitians. They provide personalized guidance on healthy eating habits and meal planning¹⁶.

By addressing nutritional needs, Medicaid aims to support more comprehensive weight management strategies. This helps improve overall health outcomes for its enrollees.

“By addressing the root causes of obesity, these evidence-based interventions aim to provide more holistic and long-term solutions for Medicaid beneficiaries struggling with their weight.”

Medicaid’s expanded focus on alternative treatment options shows a growing recognition of the need for comprehensive approaches. These innovative services can complement medication-based therapies. They deliver more effective and sustainable weight management solutions for Medicaid enrollees¹⁶¹⁷.

As we look ahead, changes in¹⁸ coverage for weight loss meds are coming. Historically, access to medicaid approved weight loss drugs was hard to get. But now, more states see the benefits and cost savings of treating obesity.

In fact², about 40% of adults and 26% of kids with obesity are on Medicaid. This shows how important it is to have anti-obesity drugs covered by medicaid. By August 2024, 13 states will cover GLP-1 meds for obesity, and more are expected to follow.

North Carolina will¹⁸ start covering FDA-approved obesity drugs on August 1st. This will help about 20,000 people. But, the cost is a big worry, with estimates of up to $3 trillion for national coverage¹⁸.

To tackle these costs¹⁸, groups are pushing for lower prices. They want prices like those in Denmark, around $200 per vial. If prices drop, more states might cover medicaid approved weight loss drugs, helping those with obesity.

Costs aren’t the only thing² states think about. They also look at health benefits, savings on chronic diseases, and fairness. As more evidence shows these meds work, and more states see their value, Medicaid’s role in fighting obesity looks brighter.

“Covering weight-loss drugs nationally for Medicare and Medicaid could cost up to $3 trillion, according to Senator Bernie Sanders.”

Medicaid’s coverage for weight loss meds, especially GLP-1s, is slowly getting better. Medicaid weight management medication has a complex situation, with different rules in each state¹⁹. GLP-1 agonists were a big part of Medicaid spending in 2022 and 2023, showing more people want these treatments¹⁹.

But, Medicaid’s coverage of GLP-1 agonists for weight management is still limited and varies a lot by state, according to a Bloomberg survey and Milliman research.

Obesity is a big problem among Medicaid users, and states are thinking about the long-term health benefits and costs²⁰. Medicaid and CHIP offer many services for obesity, like screenings and counseling, and some weight loss drugs²⁰. As new treatments and research come out, Medicaid’s coverage might change because of policy talks at state and federal levels.

The fight against obesity is getting more attention, and new treatments and Medicaid coverage offer hope for those who need help. By staying updated and pushing for better access to obesity treatments, you can help make a difference. This can improve the health of many people who rely on Medicaid.

1. Can GLP-1s for Weight Loss Be Covered by Medicaid? – https://openloophealth.com/blog/can-glp-1s-for-weight-loss-be-covered-by-medicaid
2. Medicaid Coverage of and Spending on GLP-1s | KFF – https://www.kff.org/medicaid/issue-brief/medicaid-coverage-of-and-spending-on-glp-1s/
3. Pennsylvania Medicaid Covers Newer Weight Loss Drugs – https://www.phlp.org/en/news/pennsylvania-medicaid-covers-newer-weight-loss-drugs
4. 288#12c (DMAS) Limit Weight Loss Medications in Medicaid. HB30 – https://budget.lis.virginia.gov/amendment/2024/1/HB30/Introduced/CR/288/12c/
5. Does Insurance Cover Weight Loss Medication? – https://obesitymedicine.org/blog/does-insurance-cover-weight-loss-medication/
6. Does Medicaid Cover Anti-Obesity Medication? – https://www.verywellhealth.com/does-medicaid-cover-anti-obesity-medication-8650269
7. More state Medicaid programs consider covering GLP-1 drugs – https://www.statnews.com/2024/10/23/medicaid-wegovy-saxenda-glp-1-weight-loss-drugs/
8. NC Medicaid to Cover Weight-Loss Drugs After Access Cut for State Workers – North Carolina Medical Society – https://ncmedsoc.org/nc-medicaid-to-cover-weight-loss-drugs-after-access-cut-for-state-workers/
9. NYRx Drug Class Coverage Overview: Glucagon-Like Peptide-1 Agonists – https://newyork.fhsc.com/downloads/providers/NYRx_EO_notification_20230913.pdf
10. PDF – https://medicaid.ms.gov/wp-content/uploads/2023/04/Anti-obesity-Select-Agents-PA-Criteria-V1.3.pdf
11. Anti-Acne – https://hhs.iowa.gov/media/13486/download?inline
12. Medicaid Budget Survey 2024-2025 – Pharmacy | KFF – https://www.kff.org/report-section/50-state-medicaid-budget-survey-fy-2024-2025-pharmacy/
13. Medicaid Prescription Drug Coverage: State Efforts to Control Costs – https://www.ncbi.nlm.nih.gov/books/NBK559776/
14. Coverage of Obesity Therapies in State-Regulated Markets – https://www.rwjf.org/en/insights/our-research/2024/08/marketplace-pulse-coverage-of-obesity-therapies-in-state-regulated-markets.html
15. What Weight Loss Programs Does Medicaid Cover? | HelpAdvisor.com – https://www.helpadvisor.com/medicaid/weight-loss-programs
16. New York State Medicaid Preferred Drug List – https://newyork.fhsc.com/downloads/providers/nyrx_pdp_pdl.pdf
17. Bariatric Surgery & Weight Management – NYC Health + Hospitals – https://www.nychealthandhospitals.org/bellevue/services/bariatric-surgery-weight-management/
18. Medicaid to cover weight-loss medications, state health plan members still without aid – https://www.wral.com/story/medicaid-to-cover-weight-loss-medications-state-health-plan-members-still-without-aid/21536468/
19. PDF – https://www.milliman.com/-/media/milliman/pdfs/2024-articles/1-18-24_glp1-agonists-in-medicaid-utilization-growth-and-management.ashx
20. Does medicaid cover weight loss pills – NowPatient – https://nowpatient.com/blog/does-medicaid-cover-weight-loss-pills