MaineCare, Maine's Medicaid program, provides healthcare coverage to eligible individuals based on factors like income, household size, age, and medical needs. This article delves into MaineCare's coverage policies regarding weight loss medications, eligibility requirements, and the process for accessing these benefits.
MaineCare Eligibility and Coverage Basics
MaineCare offers a range of services, including well-child exams, preventive dental care for children (VitalCare for Kids program), and coverage for individuals who are pregnant or under 21, with or without citizenship. Effective August 1, 2022, MaineCare extended postpartum coverage to 12 months after the pregnancy ends, ensuring continuous access to care during this period.
MaineCare pays for medically necessary services based on your coverage group, which is determined by your income, household size, age, medical needs, and if you need help with Activities of Daily Living. Well-Child Exams are covered by MaineCare. Your child’s health care provider will check to see if your child is healthy, and give immunizations (also called vaccines or shot) and tests (like lead screenings) if needed. Children can also get optional treatment services. Optional treatment services are medically necessary services or equipment that may be needed to prevent illness or injury to a child. MaineCare covers preventive dental care for children. Your child’s teeth and gums are checked to make sure they are healthy. Your child should go to the dentist for well-child visits starting by age one or younger. Children and young adults who are under age 21 who have MaineCare are part of the VitalCare for Kids program.
Prescription Drug Coverage and the Pharmacy Help Desk
To determine if a specific medication is covered by MaineCare, individuals can contact the Pharmacy Help Desk at 1-866-796-2463. Drugs listed as "Preferred" generally do not require prior authorization (PA). However, some medications may necessitate a PA, which involves the provider submitting a form to MaineCare for approval.
For questions about a PA for a prescription drug, call the Pharmacy Help Desk at 1-866-796-2463. You may need to pay for part of the cost of your prescription drug. For more information about PAs, see the “What is a Prior Authorization?” section below. For prescription drug benefits, medication PAs, and Medicare Part D questions, call the Pharmacy Help Desk: 1-866-796-2463.
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Discount Drug Programs
Maine offers discount drug programs for individuals who are age 62 and older or have a disability and are over the income level for MaineCare. To apply for one of the below discount drug programs, complete an application online with the Office for Family Independence at MyMaineConnection.gov. This discount drug program is for individuals who are age 62 and older or have a disability and are over the income level for MaineCare. Enrollees in these programs may receive up to 80% off the cost of their prescription drugs. If you are over the income level for MaineCare, you may get a discount on some prescription drugs.
Prior Authorization (PA)
Before you can get some services or equipment, MaineCare must approve it. This approval is called a Prior Authorization (PA). Your provider sends a form to MaineCare and we will send you and your provider a letter to let you know if the service or medical equipment is approved. For questions about a PA for a prescription drug, call the Pharmacy Help Desk at 1-866-796-2463.
Cost Sharing
You may need to pay for part of the cost of some MaineCare services. A premium is a monthly fee that some members pay to have MaineCare coverage. For some MaineCare programs, if you are over the income level for MaineCare, you may have to pay a premium for MaineCare coverage. You will know if you must pay a premium for coverage because you will get a letter from the Office for Family Independence. If you live in a medical facility, you may have to pay for a portion of your care. The Cost of Care is the amount you pay toward your care at the medical facility.
MaineCare Coverage for Obesity Treatment
Maine is taking steps to address obesity treatment through MaineCare. A bill requires the Department of Health and Human Services to provide reimbursement under the MaineCare program for glucagon-like peptide-1 receptor agonists that are approved by the federal Food and Drug Administration for the treatment of obesity. MaineCare (Maine's Medicaid program) coverage for specific weight loss medications known as glucagon-like peptide-1 (GLP-1) receptor agonists that have been approved by the federal Food and Drug Administration (FDA) for obesity treatment. The department must restrict reimbursement to medications prescribed by a primary care provider or a bariatric specialist and must require a prior authorization of the medication. This coverage comes with two key restrictions: the medications must be prescribed exclusively by either a primary care provider or a bariatric specialist, and patients must obtain prior authorization before the medication can be reimbursed.
This provision aligns with a broader trend of recognizing obesity as a treatable medical condition. The department shall provide for reimbursement under the MaineCare program for prescription drug therapy services to treat obesity that are provided by a physician licensed pursuant to Title 32, chapter 36 or 48, physician assistant licensed pursuant to Title 32, chapter 36 or 48 or nurse practitioner licensed pursuant to Title 32, chapter 31 who is part of a weight management team. For purposes of this section, "weight management team" means a multidisciplinary group of providers who provide comprehensive weight management services to a patient, including, but not limited to, behavioral health services; medical nutrition therapy; physical activity, including but not limited to physical therapy, athletic training, or kinesiology; or specialized medical services, including but not limited to services related to endocrinology, diabetes, metabolism or bariatric surgery. A provider is not required to practice in the same setting as other members of the team to be considered part of a weight management team under this section. The department shall adopt rules to implement this section.
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GLP-1 Receptor Agonists and MaineCare
The bill specifically targets glucagon-like peptide-1 (GLP-1) receptor agonists, a class of medications that have shown promise in treating obesity. Ozempic and similar drugs were originally approved by the Food and Drug Administration as diabetes medicine, but they have also been found to help control weight.
Wegovy and Medicare's Influence
Wegovy is a GLP-1 agonist, a class of obesity drugs promising a sea change in weight loss. That finding prompted CMS to change its Medicare Part D drug program to cover Wegovy, although it noted that this applies only for those patients struggling with both weight and heart disease. Obesity doctor Angela Fitch says that the move to cover it even for a limited subset of patients is still significant. "It's certainly a big step forward, compared to no coverage at all," she says. "At least now we'll have coverage for those people who have a known history of heart disease," she says. And, Fitch notes, Medicare sets the standard for coverage in insurance generally, so this move could ultimately affect more patients. The Medicare guidance could also expand the use of other similar medicines. It states that anti-obesity medications that receive FDA approval for an additional condition other than weight-management alone, can be considered a Part D drug for that specific use.
Financial Considerations
But the drugs can be pricey, with 30-day prescriptions typically around $1,000 to $1,500. Dr. “Requiring MaineCare to cover (these drugs) for treating obesity would have a significant fiscal impact. MaineCare is facing an $118 million shortfall in the current fiscal year.
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