State Health Plan Weight Loss Medication Prior Authorization Programs
The State Health Plan has experienced increased utilization and longer-term use of weight loss medications since 2010, when the prior authorization requirement for weight loss medications was removed to support the Plan’s Comprehensive Wellness Initiative. With the anticipated approval of new weight loss agents in 2012, the Plan will be implementing the prior authorization requirement on existing weight loss agents as well as new medications as of May 1, 2012, to ensure appropriate utilization. All current users (prior to May 1) will be grandfathered for 6 months until November 1, at which time they will be subject to the same coverage criteria.
Beginning May 1, all NEW USERS of weight loss medications will have to meet the following conditions for coverage:
Patient must be 12 years of age or older for Xenicalâ, and 18 years of age for all other appetite suppressants.
- Coverage is provided for either appetite suppression or weight loss in patients who are ≥30% above ideal weight or have a Body Mass Index (BMI) ≥30 kg/m2; OR patients who are 20% to 30% above ideal weight or have a BMI ≥27 kg/m2 in the presence of a comorbid condition (e.g., hypercholesterolemia, hypertension, or diabetes).
- Therapy must be used in conjunction with ANY ONE of the following: Diet, exercise, regular counseling with the doctor or another health care professional, manufacturer/organization-affiliated program OR community-based program.
- Coverage is not provided for combination use of any appetite suppressants and weight loss agents.
- Renewal criteria will also be in place for continued use after 6 months.
- Coverage conditions may be revised when the new weight loss medications are available.
To request a coverage review after May 1, providers may call Medco toll-free at 1-800-417-1764 from 8:00 a.m. to 9:00 p.m., Eastern Time, Monday through Friday, or log on to www.medco.com/coverage to request a review. Members will be responsible for the full cost of the prescription if the provider does not receive approval during the coverage review.
The Plan encourages its members to maintain a healthy lifestyle and weight and provides numerous NC HealthSmart* resources, including health coaches, nutrition visits, and access to the Eat Smart, Move More, Weigh Less classes. All resources may be found on the Plan website www.shpnc.org.
*Members eligible for NC HealthSmart services are members whose primary health coverage is through the State Health Plan.