Florida Medicaid offers healthcare coverage to eligible residents, including prescription drug benefits. However, coverage for weight loss medications can be complex, with specific requirements and limitations. This article provides an overview of how Florida Medicaid, particularly through Florida Community Care (FCC), addresses weight loss medications, including considerations around preferred drug lists, prior authorizations, and the evolving landscape of anti-obesity medications.
Understanding Florida Medicaid and Managed Medical Assistance (MMA)
Medicaid is a joint federal-state funded program that mostly serves people with lower incomes under the age of 65 or who have a disability. In Florida, Medicaid is administered through various managed care plans like Florida Community Care (FCC). FCC operates a Managed Medical Assistance (MMA) program for members without Medicare coverage, offering a Preferred Drug List (PDL) that guides prescription drug coverage.
Preferred Drug List (PDL) and Weight Loss Medications
FCC uses a Preferred Drug List (PDL), which is a list of drugs that we prefer your doctor use. The Florida Medicaid PDL is subject to revision following consideration and recommendations by the Pharmaceutical and Therapeutics (P&T) Committee and the Agency for Health Care Administration (AHCA). Medications on the PDL are organized by the therapeutic classification and includes brand and generic name along with any age limits and clinical prior authorization (PA) requirements. The PDL prioritizes generic drugs when available because they have the same ingredients as brand name drugs, but they are often cheaper than brand name drugs, and they work the same.
There are drugs that are not covered, for example some drugs for weight loss or cosmetic purposes. This means that some weight loss medications may not be included on the PDL, potentially requiring additional steps for coverage.
Exceptions to the PDL
For non‐preferred drugs, including certain weight loss medications not listed on the PDL, members have options:
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- Alternative Medications: You can ask your physician to order a similar drug that is listed on the Preferred Drug List (PDL).
- Exception Request: You can start the request for exception of a non‐preferred drug, by asking your physician to begin the request for exception process, to see if your non‐preferred drug can be covered by your benefit.
Prior Authorization (PA)
Medications on the PDL are organized by the therapeutic classification and includes brand and generic name along with any age limits and clinical prior authorization (PA) requirements. Your doctor will get prior approval for the drugs that need it.
Your doctor may want to give you a drug that is not on the PDL. Your doctor will ask an approval through Florida Community Care’s Pharmacy Department. We will reply to your doctor in (24) hours. If the request is approved, we will tell your doctor. The letter will tell you the reason for the denial. The letter will let you know how to appeal. You may be taking a drug that is no longer on our PDL. Your doctor can ask us to keep paying for this drug by requesting a prior approval. The drug must be safe and help you with your medical problem.
GLP-1 Medications and the Shifting Landscape
GLP-1s, which stand for glucagon-like peptide-1, are a class of drugs that balance blood sugar levels. They’ve long been prescribed to patients with Type 2 diabetes, and have grown in popularity among doctors and patients. These drugs, such as Wegovy and Ozempic, have shown effectiveness in weight loss. However, their high cost presents a challenge for widespread coverage. The list price for Wegovy is around $1,300 per month, and for Ozempic, around $1,000.
National and State Perspectives
The Trump administration this month scrapped a Biden-era proposal that would have required state Medicaid programs and allowed federal Medicare to pay for some GLP-1s for obesity treatments. More than a dozen state Medicaid programs have opted to cover GLP-1s for obesity treatment, and the proposed Biden rule would have asked all states to figure out how to pay for them.
In North Carolina, where 70% of people struggle with being overweight or obese, officials opted to begin covering the drugs for weight loss last year. The state has been able to afford GLP-1 coverage by negotiating rebates, or discounts, with drug manufacturers, and by getting the federal government to cover some costs. In 2023, Connecticut enacted a law requiring Medicaid to cover obesity treatment services.
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Considerations and Challenges
How and whether to cover expensive treatments and drugs can be a significant deliberation for state Medicaid directors. The Congressional Budget Office (CBO) analyzed the impact of the proposed change to cover anti-obesity medications. The CBO also cited challenges in their analysis, including (1) the rapid evolution of real-world clinical data on GLP-1 impact and effectiveness and (2) the difficulty of assessing whether weight-loss alone would reverse the weight-related chronic conditions, as well as any associated cost savings.
Accessing Medications through Florida Community Care
Pharmacy Network
Florida Community Care has contracts with certain pharmacies. You must get your drugs at one of these pharmacies. Make sure to bring your Plan ID card with you to the pharmacy. You can find a pharmacy closest to you.
90-Day Supply
Florida Community Care wants to offer a time-saving way to get select medicines. You can get a ninety (90) day supply for certain medicines. This is a great benefit. It is easy and can save you time. You don’t have to go to the pharmacy every month. For more infomation, call the Enrollee Services Department. They can help you sign up.
Specialty Pharmacy
You may need medicines to treat a complex or long-lasting condition like cancer, HIV, or multiple sclerosis. You may need to fill these prescriptions at a specialty pharmacy. FCC covers a full range of specialty prescription medications. A list of specialty medications can be found by clicking the link below. You can find this list on the State Web site. Most HIV medications should be filled by a Specialty Pharmacy. The assigned Specialty Pharmacy will arrange to have refills delivered to your place of residence or to a CVS pharmacy that you specify.
Over-the-Counter (OTC) Benefit
Florida Community Care offers a $65.00 over-the-counter (OTC) benefit every month for enrolled member. You can present your FCC ID card and the Over-the-Counter benefit list at an FCC contracted pharmacy. Please note that a generic product will be given, if on hand.
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Additional Resources
- Enrollee Services: Call 1-833-FCC-PLAN or 711 for TDD/TTY to get a copy of the Preferred Drug List, information about drugs, find out if a drug is covered, or find out how to appeal a decision.
- Pharmacy Documents and Links: Refer to your Medicare plan for more information on Prescription Drugs or call your FCC case manager if you have questions.
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