medications

"Does Medicaid Pay for Weight-Loss Drugs?"

Phat in My 40's Health Guide March 28, 2011
  • Depending upon where you live, the answer will vary.  Just like different insurance plans may have exclusions of coverage for weight loss-related programs and treatment, so do the insurance plans provided for by state Medicaid programs.

     

    As part of the Strategies to Overcome and Prevent (STOP) Obesity Alliance, the George Washington University School of Public Health and Health Services Department of Health Policy research team released a report in September 2010 titled, “A Heavy Burden: The Individual Costs of Being Overweight and Obese in the United States.”  Around the same time, GW published side-by-side reports highlighting how each state tackles obesity through insurance coverage, state regulations, and incentive programs.

     

    The question “Will Medicaid Pay for Weight Loss Drugs” is answered in the August 2010 report Medicaid Fee For Service Treatment of Obesity Intervention (pdf).  Organized by state, this research booklet provides state-specific information related to preventive coverage for adults, pregnant women and children (up to 21), coverage related to co-morbidities, pharmaceutical coverage, surgical coverage, and incentive programs.  Although Medicaid is not required to cover weight loss medications, many states have opted to add coverage for patients fitting specific criteria.

     

    Common pharmaceuticals prescribed for weight loss include the lipase inhibitors
    Xenical (Orlistat), Meridia (Sibutramine), and Adipex (Phentermine).  A lipase inhibitor works by blocking the enzyme lipase which helps to break down dietary fat.  If the consumed fat cannot be broken down, it fails to be absorbed into the blood stream and will be passed through the gastrointestinal tract instead.  The first of these medications (Xenical) was approved by the FDA in 1999.

     

    In general it appears that amphetamines, amphetamine-like drugs, and appetite suppressants are not covered when used for weight-loss purposes.

     

    No Coverage At All

     

    Twenty-seven states exclude any coverage of drugs commonly prescribed for weight-loss purposes.  These states include: Alaska, Arizona, Arkansas, Colorado, Connecticut, Delaware, District of Columbia, Illinois, Indiana, Kentucky, Maine, Maryland, Massachusetts, Mississippi, Montana, Nevada, New Mexico, North Carolina, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Utah, Washington, West Virginia, and Wyoming.

     

    Partial Coverage

     

    Some states provide coverage for lipase inhibitor drugs or amphetamines, but not specifically for the diagnosis of obesity.  These states include: Idaho, Michigan, Minnesota, Missouri, Nebraska, New York, and Oregon.

     

    Prior authorization may require that the patient have a covered diagnosis such as Type II diabetes (Minnesota), dyslipidemia (Missouri), or other condition (Nebraska, New York, Oregon).  States which specify coverage of Xenical (Orlistat) include Minnesota, Missouri, and Nebraska.  In addition to Xenical, Oregon Medicaid covers Meridia (Sibutramine) and Adipex (Phentermine).  Idaho and New York do not specify which lipase inhibitors are covered under Medicaid.

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    Coverage with Prior Authorization

     

    Eighteen states offer pharmaceutical coverage for weight-loss products provided that certain criteria are met.  These states include: Alabama, California, Florida, Georgia, Hawaii, Iowa, Kansas, Louisiana, Michigan, New Hampshire, New Jersey, North Dakota, Rhode Island, South Carolina, South Dakota, Vermont, Virginia, and Wisconsin.

     

    Within this group, states which limit coverage to Xenical (Orlistat) include Alabama, Florida, Georgia, Iowa, Louisiana, New Jersey, North Dakota, and South Carolina.  Hawaii covers Xenical (Orlistat) and Meridia (Sibutramine).  States which cover all three lipase inhibitors (Xenical, Meridia, and Adipex) under Medicaid include Kansas, Rhode Island, South Datoka, and Vermont.

     

    Coverage with Restrictions

     

    Some of the restrictions placed upon Medicaid coverage of weight-loss prescriptions are to be expected, while others are interesting.  For example, Georgia covers Xenical, but only for persons aged 12-21 and only for one year.  Rhode Island covers any weight-loss drug but for only 3 months with prior authorization.

     

    Several states (Hawaii, Iowa, Louisiana, New Hampshire, New Jersey, South Carolina) specify that weight-loss drugs are only approved for persons who have a BMI ≥ 30, or BMI ≥ 27 if the patient has a co-morbidity such as hypertension, dyslipidemia, diabetes, sleep apnea, or coronary artery disease.  North Dakota however requires that the patient start with a BMI ≥ 40 and lose at least 5% body weight in six months; once the patient’s BMI gets below 30, prescription coverage is terminated.  Requests for renewal of weight-loss drugs will be denied in Wisconsin when a patient’s BMI gets below 24.

     

    Some states (Alabama, Iowa, Michigan, Vermont) require that the patient has tried physician-supervised diet regimen unsuccessfully for six months before receiving approval for weight-loss drugs.  Other states (Hawaii, Iowa, Kansas) require that the patient successfully lose 5% of their weight in 3 months or 10% in 6 months.  Prior authorization approvals typically cover 3-6 months.  Several states (Alabama, Hawaii, Iowa, Kansas, Vermont, Wisconsin) specify that the patient must also follow a recommended treatment plan which includes things such as a reduced calorie diet, exercise, and behavioral counseling.

     

    As you can see, the requirements for Medicaid coverage of weight-loss drugs vary greatly by state.  For more information, see the report Medicaid Fee For Service Treatment of Obesity Intervention (pdf).

     

    A future post will discuss Medicaid coverage of bariatric surgery.

     

    March 20, 2011
    Weight: 232.8 lbs

     

    March 27, 2011
    Weight: 232.8 lbs

     

    Lisa Emrich is author of the blog Brass and Ivory: Life with MS and RA and founder of the Carnival of MS Bloggers.