Obesity is a growing public health concern in Michigan and across the United States, with significant implications for individual health and healthcare costs. Recognizing the importance of addressing this issue, Michigan Medicaid has taken steps to provide coverage for certain weight loss medications. This article delves into the specifics of Michigan Medicaid's coverage policies, including covered medications, eligibility criteria, and recent changes affecting access to these treatments.
Understanding Michigan Medicaid's Prescription Coverage
HAP CareSource, a Medicaid plan in Michigan, covers prescription drugs. To utilize this coverage, it is necessary to use a pharmacy within the HAP CareSource network. The plan follows a preferred drug list (PDL), or formulary, which includes drugs on the Michigan Medicaid Managed Care Preferred Drug List and Common Formulary. This list is regularly updated to include new drugs and adjust the status of existing ones. HAP CareSource provides notice of any changes to the drug list that may affect beneficiaries, allowing time to discuss alternatives with their doctors.
Formulary and Restrictions
The HAP CareSource PDL includes both prescription and covered over-the-counter drugs, as well as medications to aid in smoking cessation. Beneficiaries can search the formulary by brand or generic name to check for drug coverage.
For most medications, HAP CareSource covers up to a one-month supply, or less if prescribed by a doctor. A three-month supply is available for many drugs taken daily to treat conditions like diabetes, asthma, and high blood pressure. Birth control pills, contraceptive patches, and vaginal rings are covered for up to a twelve-month supply. Refills are subject to safety restrictions, requiring a certain amount of medication to be used before a new supply can be dispensed.
Brand vs. Generic Drugs
HAP CareSource covers both brand-name and generic drugs. In some cases, only the brand-name drug is covered, while in others, only the generic version is covered. The pharmacy will dispense the covered drug based on the plan's formulary.
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Prior Authorization
Some drugs require prior authorization before they are covered. This process ensures that the medication is appropriate for the beneficiary's treatment. Prior authorization may be necessary in the following situations:
- Step Therapy: When certain drugs must be tried before another drug is covered.
- Medical Necessity: When specific medical information is needed from the doctor to ensure the drug is appropriate for treatment, such as diagnosis information, lab test results, and medication history.
- Preferred Alternatives: When a generic drug is covered, but the brand-name drug is needed instead for a medical reason, such as an allergy to a dye in the generic medication.
- Age Restrictions or Quantity Limits: When safety concerns necessitate age restrictions or quantity limits on certain drugs.
If a needed drug is not on the formulary or there is no suitable alternative, beneficiaries or their doctors can request an exception. They can also request a waiver of restrictions or limits on a drug. Exception requests can be submitted online or by calling Member Services.
Medical Drugs
HAP CareSource also covers drugs administered in a doctor's office or facility, known as medical drugs. Some medical drugs may also require prior authorization.
Denied Requests and Appeals
If a drug request is denied, both the beneficiary and their doctor will receive a letter explaining the reason for the denial. Beneficiaries have the right to appeal the decision within 60 days of the date on the letter.
Transition of Care Policy
New Medicaid or HAP CareSource beneficiaries who are taking a drug that is not on the formulary, has restrictions, or requires approval can receive a temporary supply of the medication. This temporary supply ensures continuity of care during the transition period. For most drugs, this occurs automatically at the pharmacy. However, for certain drugs, such as those for pain, weight loss, or those requiring special monitoring, a transition supply can be requested by the beneficiary, their representative, or their doctor. This temporary supply is available for the first 90 days of enrollment with HAP CareSource.
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Drugs Not Covered
Certain drugs are not covered by HAP CareSource or mihealth Medicaid, including:
- Drugs not approved by the Food and Drug Administration
- Drugs for cosmetic use
- Experimental or investigational drugs
- Combination cough/cold medications
- Fertility drugs
- Lifestyle drugs
- Sexual or erectile dysfunction drugs
- Replacement of lost or stolen medication
- Any drug excluded for coverage by the state of Michigan
Additional Information
Beneficiaries can find information about drug costs, network pharmacies, and generic alternatives by logging into MyCareSource.com or calling Member Services.
Specialty Drugs
Specialty drugs, which require special handling and coordination with a doctor, are also covered. These drugs may require prior authorization. Examples of conditions that may require treatment with specialty medications include Crohn’s disease, hemophilia, hepatitis B and C, immune disorders, multiple sclerosis, plaque psoriasis, and rheumatoid arthritis.
Weight Loss Medications Coverage
Michigan Medicaid has recognized the importance of addressing obesity by covering several weight loss medications for individuals who meet specific criteria. These medications are primarily GLP-1 receptor agonists.
GLP-1 Receptor Agonists
GLP-1 receptor agonists are a class of medications that mimic the hormone glucagon-like peptide 1 (GLP-1). This hormone plays a crucial role in regulating appetite, blood sugar levels, and digestion. By slowing the emptying of the stomach and promoting feelings of fullness, GLP-1 agonists help individuals reduce their caloric intake, which is essential for weight loss. These medications are particularly beneficial for individuals who struggle with hunger and portion control.
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The state’s Medicaid program covers GLP-1 drugs like Ozempic, Rybelsus, Victoza and Mounjaro for Type 2 diabetes, per federal guidelines. Michigan approved additional coverage in 2022 for those seeking GLP-1s exclusively for obesity.
Covered Medications
- Ozempic: Originally approved to treat Type 2 diabetes, Ozempic has become popular for weight loss due to its ability to regulate blood sugar and suppress appetite.
- Wegovy: This medication is specifically approved for weight loss.
- Saxenda: Another GLP-1 agonist, Saxenda works similarly to Ozempic and Wegovy.
- Victoza: Primarily used to treat Type 2 diabetes, Victoza has also been prescribed off-label for weight loss in some cases.
Qualifying for Coverage
Qualifying for weight loss medications under Michigan Medicaid involves meeting specific criteria set by the program. Typically, patients must have a body mass index (BMI) of 30 or higher, or a BMI of 27 or higher with at least one obesity-related comorbidity, such as Type 2 diabetes, hypertension, or cardiovascular disease. Additionally, Medicaid may require documentation that the patient has attempted other weight loss methods, such as diet and exercise, before resorting to medication. For most Medicaid plans, obtaining weight loss medications requires pre-authorization, meaning that the healthcare provider must submit documentation proving that the patient meets the program’s criteria. This process often includes providing a detailed medical history, evidence of previous weight loss attempts, and a plan for ongoing monitoring of the patient’s progress.
Recent Changes and Restrictions
Michigan's new bipartisan state budget will limit Medicaid coverage of a group of weight loss drugs whose use has exploded in popularity in recent years. GLP-1 receptor agonists like Wegovy, Saxenda and Zepbound will be restricted in Michigan "exclusively to individuals classified as morbidly obese" under the new budget, with coverage contingent on the failure of other weight loss interventions to prevent higher-cost bariatric surgery.
Under the $81 billion state budget, which reduced funding for the Michigan Department of Health and Human Services by 20%, pharmaceutical appropriations for GLP-1 drugs were reduced by $240 million, according to the nonpartisan House Fiscal Agency.
"We are evaluating potential policy changes with the goal of implementing them effective Jan. 1, 2026.
The Broader Context of Obesity and GLP-1s
The Rise of GLP-1s
GLP-1 (glucagon-like peptide-1) drugs have been used as a treatment for type 2 diabetes for over a decade, but newer forms of these drugs have gained widespread attention for their effectiveness as a treatment for obesity. While these drugs have provided new opportunities for obesity treatment, they have also raised questions about access to and affordability of these drugs.
The Cost Factor
The drugs, which can cost $500 out-of-pocket for a one-month supply, have received much attention for their price. Michigan Medicaid paid more than $409 million in the 2024 fiscal year on GLP-1s before any discounts or price concessions.
The Impact on Medicaid
Expanding Medicaid coverage of these drugs could increase access for the almost 40% of adults and 26% of children with obesity in Medicaid. At the same time, expanded coverage could also increase Medicaid drug spending and put pressure on overall state budgets. In the longer term, however, reduced obesity rates among Medicaid enrollees could also result in reduced Medicaid spending on chronic diseases associated with obesity, such as heart disease, type 2 diabetes, and types of cancer.
State-Level Decisions
States can decide whether to cover obesity drugs under Medicaid. Under the Medicaid Drug Rebate Program, Medicaid programs must cover nearly all of a participating manufacturer’s Food and Drug Administration (FDA)-approved drugs for medically accepted indications. However, weight-loss drugs are included in a small group of drugs that can be excluded from coverage. The FDA has approved three GLP-1s for the treatment of obesity, Saxenda (liraglutide), Wegovy (semaglutide), and Zepbound (tirzepatide), and state Medicaid coverage of these is optional. However, Medicaid programs have to cover formulations to treat type 2 diabetes, including Ozempic (semaglutide), Rybelsus (semaglutide), Victoza (lirglutide), and Mounjaro (tirzepatide).
Coverage Limitations
Obesity drug coverage in Medicaid remains limited, with 13 state Medicaid programs covering GLP-1s for obesity treatment as of August 2024. All 12 states that reported coverage of GLP-1s as of July 1, 2024 also reported that utilization control(s) applied, with the most common being prior authorization (11 of 12 states) and/or BMI requirements (11 of 12 states). Eleven of the 12 states reported covering all three GLP-1s currently approved for the treatment of obesity (Saxenda, Wegovy, or Zepbound).
Cost Containment Strategies
States are likely considering various cost containment strategies for these drugs and may even be re-evaluating their broader approach to obesity treatment, including the use of obesity medications along with other treatments such as nutritional counseling or behavioral therapy.
The Long-Term Impact
The long-term benefits of covering weight loss medications extend far beyond individual patients. By helping individuals achieve and maintain a healthier weight, weight loss medications can reduce the prevalence of obesity-related conditions such as Type 2 diabetes, heart disease, and certain cancers. This, in turn, reduces the overall burden on the healthcare system, leading to lower costs for everyone.
Although weight loss medications like Ozempic and Wegovy come with a high price tag-sometimes exceeding $1,000 per month-the potential cost savings for Michigan Medicaid are substantial. By helping patients lose weight and manage their health, Medicaid can avoid paying for expensive treatments for obesity-related conditions, such as insulin for diabetes, heart surgeries, or joint replacements for arthritis. Additionally, studies have shown that losing just 5-10% of body weight can significantly reduce the risk of developing these conditions, leading to fewer hospitalizations and medical interventions.
Weight loss medications can also improve the quality of life for individuals by reducing the need for frequent doctor visits, medications for obesity-related conditions, and other costly interventions.
A Holistic Approach
While medications like Ozempic and Wegovy are highly effective at promoting weight loss, they are most successful when combined with lifestyle changes. Medicaid often supports a holistic approach to weight management that includes not only medication but also counseling on diet, exercise, and mental health. For many patients, the combination of medication and behavioral interventions produces the best results, leading to sustainable weight loss and improved overall health.
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