Can GLP-1s For Weight Loss Be Covered by Medicaid?

Obesity is a chronic disease that affects more than 30% of the US population. Obesity can also cause and worsen many other chronic diseases like type 2 diabetes mellitus, hyperlipidemia, non-alcoholic fatty liver disease, metabolic syndrome, cardiovascular disease, and obstructive sleep apnea. 

However, some of the newer and most effective medications used to treat obesity, like GLP-1s, are often expensive, with mixed coverage on insurance formularies. Medicaid is a joint federal and state healthcare coverage program that includes patients who meet specific income criteria, as well as children and other specific patient populations. On Medicaid programs, obtaining more expensive medications (including obesity medications like GLP-1 receptor agonists) is often challenging.

About GLP-1 receptor agonists

What are GLP-1s?

Glucagon-like peptide-1 (GLP-1) receptor agonists are used to treat type 2 diabetes mellitus and obesity. While most of these agents are injectable, semaglutide has an oral formulation as well.

The way GLP-1 receptor agonists work is by increasing the effects of a GLP-1, a neuroendocrine hormone that is produced in the gut in response to food intake. The most commonly prescribed GLP-1 receptor agonists for obesity are semaglutide and liraglutide.

The benefits of GLP-1s

The hormone GLP-1 helps lower blood glucose by sending it to organs and tissues to be used for energy. In addition, GLP-1 slows gastric emptying, increases fullness, reduces appetite, and leads to decreased overall calorie intake. By binding to GLP-1 receptors, GLP-1 receptor agonists increase the activity of GLP-1, improving glucose control and increasing weight loss. GLP-1 receptor agonists have also been shown to reduce the risk of cardiovascular disease.

About Medicaid

What is Medicaid?

Medicaid is a joint federal and state healthcare coverage program that is geared towards eligible individuals and families who have lower household incomes. Medicaid helps ensure that more vulnerable populations, like children, pregnant women, people with disabilities, and elderly patients, can have access to the health care they need. Medicaid applies to medical and pharmaceutical costs. 

Who is eligible?

Eligibility for Medicaid is variable depending on the state where the person lives. Medicaid eligibility usually depends on age, household income, numbers of family members, and if disabilities are present. Because of the involvement of state and federal governments, different states have specific rules for Medicaid implementation, under overall federal guidelines.

Medicaid coverage for prescription medications

Details about coverage

Medicaid provides coverage for a wide range of prescription medications. However, like many other insurance organizations, Medicaid gives preference of affordable coverage to specific medications. Some insurances call this a drug formulary; for Medicaid, this is each state’s preferred drug list. What drugs are covered and their costs vary by state. 

Overall challenges

Medicaid’s preferred drug list is usually a clear-cut, black-and-white rule of what medications are covered on the plan. Yet, their preferred drug list usually changes each quarter, so it’s not a learn it and remember it situation. Rather, providers and patients have to continue to check the preferred drug list, especially for the more costly medications.

Medicaid is also notorious for requiring prior authorizations (PAs). PAs require that the prescriber clearly demonstrate why patients need the medication before Medicaid may approve its coverage. Usually this means showing that patients have tried cheaper medications, but they were ineffective. For example, if a patient is prescribed Ozempic (semaglutide) for type 2 diabetes mellitus, Medicaid usually requires evidence that the patient tried metformin first and did not achieve the glucose control they needed. 

Lastly, like other coverage plans, Medicaid usually charges copayments (the cost of the medication the patient pays). Medicaid also often limits the amount of each medication a patient can fill in a given period of time.

Medicaid coverage of GLP-1s

Factors influencing Medicaid coverage for GLP-1s

Medicaid coverage for GLP-1 receptor agonists depends on a number of things. Because each state runs its Medicaid under federal guidelines, state-specific policies impact GLP-1 receptor agonist coverage. Additionally, GLP-1 receptor agonists almost always require PAs (if they are covered at all). To describe GLP-1 receptor agonist coverage more specifically, the indication (type 2 diabetes mellitus vs. obesity) is very important. Medicaid is much more likely to cover a GLP-1 receptor agonist for type 2 diabetes than they are for obesity. 

Variations in state coverage

Although achieving Medicaid coverage for GLP-1 receptor agonists for obesity is often challenging, variations in coverage across different states are common. Patients with Medicaid coverage who desire to take a GLP-1 receptor agonist for obesity are more likely to have it approved if they have failed over less expensive agents for obesity.

Compounded semaglutide and Medicaid

What is compounded semaglutide?

Compounded medications are prepared by a licensed pharmacist, as opposed to being mass-produced within a pharmaceutical company. Compounded medications may be used to meet the needs of specific patients, or they may aim to alleviate drug shortages when commercial drugs are unavailable. 

As injectable semaglutide has become increasingly popular, it has caused shortages of multiple semaglutide forms. Compounded semaglutide has become more available to meet the need. However, because compounded medications are not FDA-approved, patients need to use caution when taking compounded medications (like semaglutide). Look for trusted companies that use compounding pharmacies that are FDA-monitored, likeAgile Telehealth, to ensure medication quality and safety.

Are compounded medications covered by Medicaid?

Whether compounded medications are covered by Medicaid varies by state. In nearly all cases, coverage of compounded medications is more restrictive than commercially available medications. For a chance at coverage, medical necessity must be proven with no suitable commercially available alternatives. 

Is compounded semaglutide affordable without coverage?

In the event that neither commercially available semaglutide nor compounded semaglutide are covered by Medicaid, there are affordable cash-pay options too. However, before opting for the cheapest semaglutide available, be sure to ensure the sources of the ingredients and any safety data you can find. Always talk to your healthcare professional before starting, stopping, or changing any medication.

At Agile, we’re committed to the highest level of quality and patient safety. Our compounded GLP-1 medications are manufactured by our network of trusted, FDA-monitored compounded pharmacy partners. Additionally, our NCQA-credentialed network of providers offer clinical oversight throughout the entire treatment process to monitor efficacy, side effects and dosage.

Interested in learning more? You can schedule a no-cost consultation with a provider to see if one of our GLP-1 programs is a fit. See if you qualify today!