Medicaid consumers in Pennsylvania who have been prescribed medication for obesity treatment may be able to get these medications covered if they meet specific criteria. Independence Blue Cross (IBX), however, will no longer offer coverage for drugs indicated and prescribed solely for weight loss in the absence of other FDA-approved clinical indications, effective January 1, 2025. It is important to understand the nuances of coverage, prior authorization requirements, and available support systems to navigate this landscape effectively.
Medicaid Coverage in Pennsylvania
Medicaid coverage of weight loss drugs is available to participants who meet the prior authorization criteria. This is particularly significant for individuals who are “dual eligibles,” meaning they have both Medicaid and Medicare. While Medicaid typically does not provide drug coverage for dual eligibles (who usually rely on Medicare Part D for prescription drug benefits), Medicaid can cover certain medications excluded from Part D. Medicare Part D specifically excludes prescription medications used solely for weight loss.
Prior Authorization Criteria
In order for Medicaid to cover weight loss drugs, a doctor must submit a prior authorization request detailing that the patient meets the coverage criteria. Generally, adults over age 18 must have a body mass index (BMI) of 30 or higher, or a BMI of 27 or higher with 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 face 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). This requirement likely means people on both Medicare and Medicaid who have diabetes and are prescribed weight loss medications 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 diabetes drugs that have a weight loss version, but coverage may vary depending on the plan's formulary (list of covered drugs).
Appealing a Denial of Coverage
Individuals have the right to appeal if Medicaid denies coverage for weight loss drugs after a doctor submits the prior authorization showing the patient meets the criteria.
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Independence Blue Cross (IBX) Changes in Coverage
Effective January 1, 2025, Independence Blue Cross (IBX) will no longer offer coverage for drugs-including glucagon-like peptide-1 receptor antagonist (GLP-1) and non-glucagon-like peptide-1 receptor antagonist (non-GLP-1)-indicated for and prescribed solely for weight loss in the absence of other FDA-approved clinical indications. Medicare will allow coverage for Wegovy® when prescribed for the cardiovascular indication. IBX will continue to provide coverage for GLP-1 drugs prescribed to patients (members) for FDA-approved medical conditions and indications, including type 2 diabetes and cardiovascular disease, with prior authorization. This change will take effect on January 1, 2025, or when their coverage plan renews.
Impacted members may be able to use their Health Savings Account (HSA) or Flexible Spending Arrangement (FSA) dollars, if eligible.
Rationale Behind the Coverage Change
IBX took several factors into consideration, including the responsibility to provide the best value of health care coverage to its members. This includes balancing drug coverage with associated increases in premiums to pay for the drugs. Higher premiums affect all members, whether they receive weight loss drugs or not. The cost of these drugs in the United States is almost 10 times more than in other parts of the world.
IBX Support for Weight Management
IBX emphasizes that the cornerstone of healthy living and any weight management journey includes lifestyle changes such as diet, exercise, and behavioral modifications. IBX offers several benefits to help members on their weight management journey, including:
- Outpatient nutrition and behavioral health counseling
- Reimbursements for fitness center fees, weight management programs, and other health-related programs
- Lifestyle management programs that offer clinically proven support for weight management, nutrition, stress relief, and more
- Bariatric surgery for members with health risks from being obese
Members should visit the IBX member site to review the different benefits that may be available to them, as coverage of the listed services depends on the member's health plan.
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Checking Wegovy® Coverage and Savings Options
Novo Nordisk®, the maker of Wegovy®, offers a platform where individuals can check their insurance coverage for Wegovy® and access savings offers.
How to Check Coverage
- Go to the platform and select whether you're a patient or caregiver.
- Enter your insurance details.
- Provide key information including your name, date of birth, gender, and zip code.
- Review the information and check the consent box.
- Enter your health care professional's first and last name, city, and state.
Based on the answers submitted, you’ll find out if your insurance covers Wegovy®.
Possible Coverage Results
- Covered: If you have commercial insurance and are covered or covered with prior authorization, talk to your health care professional about whether Wegovy® could be right for you. The Wegovy® savings card can help lower those costs. Government insured patients cannot use any copay cards offered by the manufacturer.
- Prior Authorization Required: It means that your health insurance company might need to approve your prescription. Your health care professional will fill out a prior authorization form and submit it to the insurance company. The insurer will look at the prior authorization to determine whether they will cover the medicine under your insurance plan. It will communicate its decision and rationale to you and/or your health care professional. If your result is not covered, you may submit an appeal or request for coverage with the help of your health care professional.
- Not Covered: If your insurance doesn't provide coverage, or is unable to provide immediate coverage details, explore options that may help.
- Undetermined: This means that more information is needed.
GLP-1 Receptor Agonists and Weight Loss
All three weight loss medications for obesity treatment are in a class of drugs called GLP-1 receptor agonists, which have been used to treat diabetes for several years. Each of the newer weight loss drugs now on the Medicaid preferred drug list has a version of the medication used for diabetes treatment.
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