Reply to Is WEGOVY covered by DC Medicaid?

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Reply to "Is WEGOVY covered by DC Medicaid?"

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[quote=Anonymous]I am on medicaid but in Virginia, so my input is only applicable in a general sense.

With medicaid, wegovy is on most of their formularies. This means that most medicaid plans are going to cover it for at least some patients.

However, just because it is on the formulary as something that medicaid can cover does not guarantee that it will be covered for a specific patient.

Medicaid will only cover it if your doctor prescribes it in a way that convinces medicaid it is "medically necessary".

It is easiest to get wegovy covered if the patient is obese, has tried other methods to lose weight, and currently has one or more medical conditions that are probably caused or severely worsened by their weight, in the medical judgement of their doctor. In that case wegovy would help the patient lose the weight (when other methods had failed) which would fairly directly result in an improvement or remission/removal of an active medical problem --> relatively clear medical necessity.

In the case that a patient is obese, has tried other ways to lose weight that haven't been very effective, and the doctor uses best medical judgement to say that the patient is at risk of developing a serious medical problem like diabetes mainly due to the obesity, and that the patient losing significant amounts of weight would likely prevent development of the condition, medicaid might cover the wegovy because medicaid does cover some preventative health care services etc. It is in both the patient's and medicaid's best interest for the patient to not develop a serious, chronic, expensive to manage medical condition, so a strong case could probably be made.

Medicaid is least likely to cover wegovy to prevent possible development of diabetes in the case of a patient who is either overweight short of obesity or who has not tried other methods of weight loss and found them ineffective/insufficient.[/quote]

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