Does Medicaid Cover Anti-Obesity Medication?

Two-thirds of Medicaid beneficiaries have obesity or chubby, but that doesn’t necessarily mean recipients of the government-funded low income insurance program have wider access to latest weight management medications.

Only 16 states list glucagon-like peptide (GLP-1) receptor agonists, a more moderen class of injectable medications used for each diabetes and weight reduction, on their covered drug lists, in line with a Fall 2023 report from health research firm KFF. The report focused on Medicaid prescriptions for Ozempic, Rybelsus, Wegovy, and Mounjaro (the latter of which can also be a GIP receptor antagonist). Of these medications, only Wegovy is technically FDA-indicated for weight reduction; the others are type 2 diabetes medications used “off-label” to assist patients shed pounds.

“From Medicaid data publicly available, there is no such thing as a way yet to disentangle how much of the growing use of those drugs is said to treatment for diabetes versus obesity, or a mix of each,” the report says.

While Medicaid is required by law to cover any Food and Drug Administration (FDA) approved drug, there’s an exception for coverage of medication for weight management, cosmetic needs (corresponding to wrinkles), and cough and cold medicines.

“State Medicaid programs can cover the injectable drugs, but they don’t need to,” Liz Williamsa senior policy analyst for the Program on Medicaid and the Uninsured at KFF, told Verywell.

Importantly, that is more lenient than Medicare coverage rules, which prohibit the coverage of medication for obesity or weight reduction altogether.

There’s hope that more states will add Medicaid coverage for anti-obesity medications in the course of the current state legislative session as budgets are discussed, Kate McEvoy executive director of the National Association of Medicaid Directors, told Verywell.

Each state’s Medicaid website features a formulary (an inventory of covered drugs) where you may check if GLP-1 medications—or other weight management drugs—are covered specifically for the indications of obesity, chubby, and/or weight reduction.

States With Coverage May Have Specific Rules

Even in states where anti-obesity medication is roofed, Medicaid beneficiaries may face hurdles when procuring prescriptions. According to a report by actuarial firm Milliman, current Medicaid rules in Virginia, for instance, require patients who’re searching for GLP-1 medications for chronic weight management to get a letter from the doctor stating that their weight is disabling and life-threatening. They are required to have tried a drug from a special class of medication and failed to profit from it throughout the past six months before getting approval to make use of a GLP-1.

In Michigan, Medicare authorization is contingent on a physician’s letter stating that the drug is a component of a comprehensive treatment plan for weight management, including eating regimen and exercise.

When it involves reauthorizing GLP-1 Medicare coverage for somebody already taking the medication for weight management, Mississippi, Virginia, and Michigan each require proof of weight maintenance or improvement to point the drug is working.

These hurdles exist because state Medicaid budgets can’t afford to cover everyone who would profit from the drug. While some private insurers charge higher copays to assist offset the fee of the drugs, Medicaid copays are capped at not more than $8 for drugs that aren’t on the popular drug list, Wayne Turner, a senior attorney on the National Health Law Program in Washington, DC, told Verywell.

While it might be some time before all state Medicaid programs cover drugs specifically for weight reduction, if a GLP-1 is approved for an additional indication within the meantime, Medicaid would need to cover it for that use in every state—and weight reduction might be a side profit. This recently happened with Wegovy, which earned FDA approval in March to scale back the danger of heart attack, stroke, and other cardiovascular problems in adults with heart disease who’ve obesity or chubby. Previously, it was only indicated for weight management.

GLP-1 manufacturers are investigating them for other uses, including sleep apnea and treatment of addiction. If the FDA approves those indications, Medicaid will cover them, Turner said.