07 Jun, 2024
Unlike private insurers, which often offer new weight loss drugs on their preferred drug lists, most Medicaid programs have not done so. However, the trend may be changing as lawmakers recognize that obesity is a disease and should be treated like any other illness. A nuanced interplay of eligibility requisites — including a body mass index (BMI) that eclipses a threshold, demonstrating medical exigency precipitated by obesity-associated comorbidities and faithful adherence to prescribed dietary and physical regimens — characterizes the accessibility of these medicines under Medicaid’s aegis. State Medicaid programs determine what prescription drugs they will cover. As of July 2023, California, Connecticut, Michigan, Minnesota, Rhode Island, and Wisconsin provide comprehensive coverage for GLP-1 drugs such as Wegovy. However, some states have specific stipulations or require patients to try less expensive drugs first before the medication will be approved. In Colorado, for example, Wegovy is only covered if it’s being used to reduce the risk of heart attack and stroke in patients with cardiovascular disease and obesity or overweight as specified by the Food and Drug Administration. McCullough doesn’t have cardiovascular disease, so she wouldn’t qualify for the coverage. The rules also differ on a state-by-state basis as some are required to cover certain medications if federal grants are received for their development and others do so because they want to improve the health outcomes of their constituents. In addition, the way in which an individual is assessed for coverage depends on how their income compares to the federal poverty line. If they are found to be below the poverty line, they will not be eligible for Medicaid but can still qualify by “spending down,” incurring expenses that push their income below a state’s medically needy standards. Despite the complexities of the system, an individual seeking approval to receive a prescription for these weight management medications should know that it is possible. However, if they are denied and believe the decision was based on an error or that the agency has not acted with reasonable promptness, they have the right to file an appeal. A variety of reasons may be given for a claim to be denied, including the fact that the medication is considered experimental or off-label, or the fact that the individual has already tried a less-expensive drug or an alternative treatment. If the denial is upheld, an individual can appeal the decision to a state agency or to the Department of Health and Human Services (HHS). In determining whether or not a claim should be granted, HHS looks at several factors, including the type of drug being sought and whether it will have a positive impact on the health of the beneficiary. If a claim is not approved, an individual can seek a fair hearing, in which they can present evidence and testimony regarding the claims. If they are successful, the claim will be reversed. If the claim is not reversed, HHS will notify the individual and explain why the request was denied.