Unlock Indiana Medicaid Secrets: Your Ultimate Guide to Weight Loss Medication Coverage!

Obesity is a significant health concern in Indiana, with almost 38% of Hoosiers classified as obese, according to the Centers for Disease Control and Prevention. This has led to increased attention on weight management and treatment options, including medication. Understanding Indiana Medicaid's coverage for weight loss medications is crucial for both healthcare providers and eligible members. This article provides a detailed overview of Indiana Medicaid's policies regarding weight loss medications, drawing from recent announcements, program updates, and established guidelines.

Overview of Medicaid Coverage for Obesity Treatment

Across the United States, Medicaid programs are being scrutinized for their coverage of comprehensive obesity care, which includes nutrition counseling (NC), intensive behavioral therapy (IBT), obesity medications (OM), and metabolic and bariatric surgery (MBS). A study by the STOP Obesity Alliance, in partnership with the Obesity Action Coalition, analyzed state Medicaid programs, reviewing both Managed Care Organization (MCO) and Fee for Service (FFS) plans to determine the extent of coverage for these treatments.

Methodology of Coverage Review

The study employed LEVERAGE, a consulting firm, to extract Medicaid coverage data for the plan year 2023. This involved identifying relevant source materials and documents to determine coverage and the associated criteria. The extracted data was then categorized based on whether a benefit was covered, not covered, covered with limitations, or covered with restrictions. Limitations were defined as criteria that must be met at the patient level, such as clinical parameters, while restrictions represent barriers to accessing covered treatments. A novel scoring approach was used to analyze the level of obesity treatment coverage in each state.

Indiana Medicaid's Coverage Policies

General Guidelines

Indiana Medicaid generally covers medically necessary services for eligible individuals. However, specific guidelines and restrictions apply to weight loss medications. It's important to note that coverage policies can vary based on the specific Medicaid plan (HIP, Hoosier Healthwise, or Hoosier Care Connect), and members should always verify coverage details with their respective health plans.

Weight Loss Medications Covered

Indiana Medicaid may cover two weight-loss medications for eligible Medicaid members under the age of 21 through the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) program. The state covers nutrition counseling. The state covers intensive behavioral therapy, though few states were explicit about this coverage. The state will cover obesity medications for the specific purpose of treating obesity (not to treat Type 2 diabetes with obesity as a secondary condition). The drugs covered for obesity were reviewed from the state fee for service (FFS) and the managed care organization (MCO) Prescription Drug List (PDL) of the MCO with the greatest number of enrollees. There are restrictions on coverage based on age. The patient must achieve a specific amount of weight loss for the medication to be renewed. The state includes coverage for metabolic and bariatric surgery (MBS). There are restrictions on coverage based on age, i.e. only 18-64y is covered, <21y is not covered, or >65y is not covered.

Medications Not Covered

Certain medications are explicitly not covered by Indiana Medicaid, including:

Medications made by manufacturers that do not participate in the Medicaid program.
Medications that do not have an FDA-approved use.
Medications that are not medically necessary.
Experimental or investigational medications.
Medications to help you get pregnant.
Medications used for weight loss.
Cosmetic or hair-growth medications.
OTC medications not on the OTC Drug Formulary.

Preferred Drug List (PDL) and Prior Authorization

Indiana Medicaid utilizes a Preferred Drug List (PDL) to guide prescription coverage. The PDL categorizes drugs as either "preferred" or "nonpreferred." Preferred drugs typically do not require prior authorization, while nonpreferred drugs generally do. A team of doctors and pharmacists updates the PDL four times a year to ensure that the drugs are safe and cost effective for the Indiana Medicaid program.

Prior authorization is a process where a doctor must provide information about a patient's health condition to determine if a medication is appropriate. A prior authorization request is necessary if:

A drug is listed as nonpreferred on the PDL.
Certain conditions must be met prior to receiving the drug.
The prescription exceeds the typical limit.
There are other drugs that should be tried first.

In cases requiring prior authorization, a 72-hour supply of the medication may be provided while awaiting a decision. The prior authorization decision is typically made within 24 hours of receiving the request (excluding Sundays and some holidays), and the doctor will be notified. If a prior authorization request is denied, the patient has the right to appeal.

Restrictions and Limitations on Coverage

Coverage for weight loss medications under Indiana Medicaid may be subject to several restrictions and limitations:

Age Restrictions: Some weight loss medications may have age restrictions, such as being covered only for individuals between 18 and 64 years of age.
Weight Loss Requirements: Patients may need to demonstrate a specific amount of weight loss for the medication to be renewed.
Medical Necessity Criteria: Coverage often depends on meeting specific medical necessity criteria, such as BMI levels and the presence of co-morbid conditions.
Substance Use Disorder (SUD) History: A patient could be excluded from coverage if there is a history of substance use disorder (SUD) now or in past; some states exclude patients with a SUD within a certain time, i.e.
Compliance with Post-Operative Programs: The criteria that must be met for a repeat bariatric and metabolic surgery to be approved includes a requirement that the patient (and/or provider) provide proof of compliance with all previously prescribed postoperative nutrition and exercise programs.

Recent Updates and Potential Changes

The landscape of weight loss medication coverage is constantly evolving. Recent announcements and proposed rule changes may impact Indiana Medicaid's policies.

IHCP Updates

Indiana Health Coverage Programs (IHCP) regularly releases updates that may affect healthcare practices. Recent updates include changes to the SilentAuth automated prior authorization system, PA criteria, Over-the-Counter (OTC) Drug Formulary, and Statewide Uniform Preferred Drug List (SUPDL). Additionally, IHCP has begun enrollment for Medicare-only providers (provider type 37, specialty 370) that serve dually eligible (Medicare and Medicaid) members.

Potential Impact of Federal Rule Changes

The White House announced a planned new rule in November that would greatly expand Medicare Part D and Medicaid coverage for popular medications such as Eli Lilly and Co.’s Zepbound and Novo Nordisk’s Ozempic and Wegovy to treat obesity alone. However, the proposed new rule will be handed off from the Biden administration to the incoming Trump Administration, creating uncertainty about its approval and implementation path.

A report from the Penn Wharton Budget Model economic analysis and public policy research group estimates that if the proposed rule becomes a reality in 2026, 14 million Medicare and 33 million Medicaid beneficiaries would be newly eligible for coverage of weight drugs.

Cost Implications

The Indiana Family and Social Service Administration’s Office of Medicaid Policy and Planning estimated in December that if weight-loss medications were more widely covered, 5% to 20% of eligible members would be prescribed them, costing $11 million to $70 million a year.

Read also: Weight Loss Meds & BCBS

Navigating Pharmacy Benefits

Understanding the pharmacy benefits under Indiana Medicaid is essential for accessing covered medications.

Generic vs. Brand Name Drugs

Indiana law requires that generic drugs be dispensed when available, with some exceptions. Generic drugs are as safe and effective as brand name drugs but are typically less costly. Brand name drugs may be dispensed if generic drugs are not available or if Indiana Medicaid determines that the brand name drug is less costly.

Days' Supply Limit

Drugs taken for a long time (maintenance drugs) have higher supply limits, while drugs taken for a shorter time (non-maintenance drugs) are likely to have a 30-34 days' supply limit.

Drug Copayments

Some members may have to pay a copay for each drug. However, copays cannot be charged in certain instances, such as:

Prescriptions for members under the age of 18.
Prescriptions related to a pregnancy.
Prescriptions related to family planning.
Prescriptions while in an emergency room or nursing home.
Prescriptions while in a hospital.
Prescriptions dispensed as an emergency supply.

Resources and Contact Information

For questions about pharmacy benefits or help finding a pharmacy, members can contact their health plan or OptumRx's Clinical/Technical Help Desk. Contact information can be found on the Contact Us page of the Indiana Medicaid website.

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