This article provides a detailed overview of weight loss medication coverage, focusing on changes in Medicaid policies and access to medications like Wegovy, Zepbound, and Saxenda. It is designed to help beneficiaries, families, and providers understand the current landscape and navigate the evolving coverage criteria.
Changes in North Carolina Medicaid Coverage Effective October 1, 2025
Effective October 1, 2025, North Carolina Medicaid will discontinue coverage for GLP-1s for the treatment of obesity due to shortfalls in state funding. This change applies to both NC Medicaid Direct and NC Medicaid Managed Care. While NC Medicaid remains committed to the potential of GLP-1s for obesity treatment, current funding limitations prohibit continued coverage for weight management purposes.
Continued Coverage for Other Indications
GLP-1s will continue to be covered for specific indications, including:
- Diabetes
- Reduction in cardiovascular death, heart attack, and stroke in obese adults with cardiovascular disease
- Noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)
- Severe obstructive sleep apnea (OSA)
Specific Medication Changes
- Wegovy, Zepbound, and Saxenda: These medications will be removed from the Preferred Drug List (PDL) as an off-cycle change, effective October 1, 2025.
- Saxenda: Will no longer be covered for any indication.
- Non-Incretin Mimetics: This class of drugs for obesity treatment will continue to be managed through the PDL. Preferred drugs include diethylpropion, phendimetrazine, and phentermine, which do not require prior approval.
- Wegovy and Zepbound: Coverage will be managed through prior authorization, using clinical criteria established by the State for FDA-approved indications.
Prior Authorization Requirements
Providers will need to obtain a new prior authorization for beneficiaries receiving Wegovy and Zepbound, effective October 1, 2025. Current prior authorizations will no longer be valid after September 30, 2025. Prior authorization requests can be submitted beginning October 1, 2025.
Wegovy: Continued Coverage for Specific Conditions
Wegovy will continue to be covered for:
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- Reducing the risk of cardiovascular death, heart attack, and stroke in adults with cardiovascular disease who are obese.
- Treating noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), formerly known as nonalcoholic steatohepatitis (NASH), with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults.
Zepbound: Continued Coverage for Obstructive Sleep Apnea
Zepbound will continue to be covered for treating moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
No Changes for Diabetes Treatment
There will be no changes to coverage for GLP-1 medications used for the treatment of diabetes. Additionally, Weight Management (Non-Incretin Mimetics) will still be covered as listed on the PDL.
NC Medicaid Commitment
More than 3.1 million North Carolinians have health care coverage through Medicaid. The changes may place a burden on beneficiaries, their families, and providers.
Pennsylvania Medicaid Coverage Criteria
Medicaid consumers in Pennsylvania who are prescribed medication for the treatment of obesity may be able to get these medications covered if they meet certain criteria. Medicaid coverage of these weight loss drugs is available to participants who meet the prior authorization criteria (described below).
Dual Eligibles
This includes people who have both Medicaid and Medicare, known as “dual eligibles”. Typically, Medicaid does not provide drug coverage for dual eligibles. Dual eligibles must get their medications covered through Medicare Part D (Medicare’s prescription drug benefit). However, Medicaid can cover certain medications excluded from the Medicare Part D benefit. Medicare Part D coverage rules specifically exclude coverage of prescription medications used solely for weight loss. Another example of excluded Part D drugs that are covered by Medicaid for dual eligibles are over-the-counter medications.
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Prior Authorization Requirements in Pennsylvania
In order for Medicaid to cover these new weight loss drugs, a person’s doctor must submit a prior authorization request detailing that the patient meets the coverage criteria. Generally, to get these drugs covered, adults over age 18 must have a body mass index (BMI) of 30 or higher (or 27 or higher with certain additional requirements), and they must have at least one weight-related health condition.
Additional Requirements for Individuals with Diabetes
People who have diabetes or have used a diabetes drug in the previous 120 days have an additional requirement: they must try and fail treatment on one of the preferred diabetes treatment versions of the weight loss drugs, or another preferred diabetes drug in the same drug class (GLP-1 receptor agonists).
Implications for Dual Eligibles with Diabetes
The requirement to try and fail on one of the diabetes treatment drugs likely means people on both Medicare and Medicaid who have diabetes who are prescribed one of the above medications for obesity treatment/weight loss will need to seek coverage of a diabetes version of a weight loss drug through their Medicare Advantage Plan or Medicare Part D drug plan. Medicare plans do cover the diabetes drugs that have a weight loss version but may not cover all of these medications on their formulary (list of covered drugs).
Right to Appeal
People have a right to appeal if Medicaid denies coverage for the new weight loss drugs after a doctor submits the prior authorization showing the patient meets the criteria.
Navigating Weight Loss Medication Coverage
Understanding the specific criteria for coverage is crucial for both patients and healthcare providers. Here's a step-by-step guide to navigating the process:
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Consult with a Healthcare Provider: Discuss weight loss goals and potential medication options with a healthcare provider. They can assess eligibility based on BMI, health conditions, and medical history.
Understand Prior Authorization Requirements: Familiarize yourself with the specific prior authorization requirements for the prescribed medication in your state's Medicaid program. This often includes documentation of BMI, related health conditions, and previous treatment attempts.
Gather Necessary Documentation: Collect all necessary medical records and documentation to support the prior authorization request. This may include lab results, physician notes, and records of previous treatments.
Submit Prior Authorization Request: Work with your healthcare provider to submit the prior authorization request to Medicaid. Ensure all required information is complete and accurate.
Address Denials: If the prior authorization request is denied, understand the reason for the denial and explore options for appeal. Document and address the reasons that the request was denied and resubmit with all the information.
Explore Alternative Options: If coverage for preferred medications is not available, discuss alternative treatment options with your healthcare provider. This may include non-preferred medications, lifestyle modifications, or other weight management programs.
Stay Informed: Stay updated on any changes to Medicaid policies or coverage criteria for weight loss medications. Regularly check with your state's Medicaid program or consult with a healthcare professional.
The Role of GLP-1 Receptor Agonists
GLP-1 receptor agonists are a class of drugs that have been used to treat diabetes for several years. These medications work by mimicking the effects of the naturally occurring hormone GLP-1, which helps to regulate blood sugar levels and promote weight loss. Several GLP-1 receptor agonists have been approved for the treatment of obesity, including Wegovy, Zepbound, and Saxenda.
Benefits of GLP-1 Receptor Agonists
- Weight Loss: GLP-1 receptor agonists have been shown to be effective in promoting weight loss in individuals with obesity.
- Blood Sugar Control: These medications can help to improve blood sugar control in people with diabetes.
- Cardiovascular Benefits: Some GLP-1 receptor agonists have been shown to reduce the risk of cardiovascular events in people with diabetes and cardiovascular disease.
Considerations for GLP-1 Receptor Agonists
- Side Effects: GLP-1 receptor agonists can cause side effects such as nausea, vomiting, diarrhea, and constipation.
- Cost: These medications can be expensive, and coverage may vary depending on insurance and Medicaid policies.
- Prior Authorization: Many insurance plans require prior authorization for GLP-1 receptor agonists, which may involve meeting certain criteria such as BMI and related health conditions.
Non-Incretin Mimetics for Weight Management
Non-Incretin Mimetics are another class of drugs used for weight management. These medications work through different mechanisms than GLP-1 receptor agonists and may be an option for individuals who are not eligible for or cannot tolerate GLP-1 receptor agonists. Examples of Non-Incretin Mimetics include diethylpropion, phendimetrazine, and phentermine.
Considerations for Non-Incretin Mimetics
- Availability: Non-Incretin Mimetics are generally more affordable and easier to access compared to GLP-1 receptor agonists.
- Side Effects: These medications can cause side effects such as increased heart rate, high blood pressure, and insomnia.
- Prior Authorization: Some insurance plans may require prior authorization for Non-Incretin Mimetics, although many preferred drugs do not require prior approval.
Addressing the Obesity Epidemic
Obesity is a significant public health concern, affecting millions of people worldwide. It is associated with an increased risk of various health conditions, including diabetes, heart disease, stroke, and certain types of cancer. Effective weight management strategies are essential for preventing and managing obesity and its related complications.
Comprehensive Approach to Weight Management
A comprehensive approach to weight management involves a combination of lifestyle modifications, medical interventions, and ongoing support. This may include:
- Dietary Changes: Following a healthy and balanced diet that is low in calories, saturated fat, and added sugars.
- Physical Activity: Engaging in regular physical activity, such as aerobic exercise and strength training.
- Behavioral Therapy: Addressing emotional and psychological factors that contribute to overeating and weight gain.
- Medications: Using weight loss medications, such as GLP-1 receptor agonists and Non-Incretin Mimetics, under the guidance of a healthcare provider.
- Surgery: Considering bariatric surgery for individuals with severe obesity who have not been successful with other weight management strategies.
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