Christine Ferguson
Professor
George Washington University
School of Public Health and Health Services
Department of Health Policy
Director, STOP Obesity Alliance

Bringing together comprehensive data on obesity-related coverage for all 50 states and the District of Columbia in a single place provides a unique way to compare information.
» The GW research team compiled a comprehensive state-by-state survey of obesity-related insurance regulation and coverage of services under Medicaid and state employee benefit plans.
» Particular Areas of Focus:
– Lifestyle Programs (generally), e.g., gym memberships, Weight Watchers, nutritional or other health related educational services
– Lifestyle Programs for Pregnant Women, e.g., risk assessment, nutritional counseling, education on breast feeding
– EPSDT Services (Medicaid)
– Coverage for Co-Morbidities Associated with Obesity, e.g., diabetes, hypertension, COPD, coronary artery disease, asthma, sleep apnea
– Coverage of Anti-Obesity Medications (Anorectics), e.g., Xenical, Meridia,
Phentermine
– Coverage of Bariatric Surgery, e.g., covered procedures and eligibility requirements (BMI, presence of co-morbidity, failed attempts at weight management through diet and exercise)
– Incentive Programs, e.g. reduction in cost-sharing as reward for maintaining a specified health status factor, such as BMI or smoking cessation

» State Medicaid Policy:
– Title XIX State Plans
(Medicaid)
– State statutory and regulatory provisions related to coverage for services
– State Medicaid agency prior authorization forms
– State Medicaid agency prescription drug formularies
– State Medicaid agency member benefit handbooks
» State Employee Benefit
Plans:
– Summary Plan
Documents for each of the plans offering state employee benefits
– Member handbooks for each of the plans (if necessary)
– Plan-specific prior authorization requirements for bariatric surgery
– Pharmacy Benefit
Manager (PBM) formulary and prior authorization requirements
State Insurance Mandates
» Surveyed insurance codes and regulations related to small group and individual health plans
» Focused on eligibility and rate adjustments that involved obesity or health status
» Focused on obesityrelated treatment (if the state addressed this issue at all, it was in the realm of wellness and prevention)

» Preventive Services (Adults): May be available if approved through prior authorization process
» Preventive Coverage (Pregnant Women): Prenatal Care:
Services for any other medical conditions that may complicate the pregnancy are provided with no limitation, so long as the services are covered under Medicaid and are related to the pregnancy
» Preventive Coverage (Children up to age 21): EPSDT: If nutritional assessment suggests a dietary inadequacy or presence or risk of obesity, further assessment factors are indicated:
– family, socioeconomic or community factors
– quality and quantity of individual diet
– physical and laboratory exams
– prevention, treatment, and follow-up services such as dietary counseling and nutrition education
» Coverage Related to Co-Morbidities: D.C. Medicaid does not appear to offer a separate set of covered services for chronic disease management.

» Pharmaceutical Coverage
– Weight Loss Drugs: Weight loss drugs (Orlistat and
Sibutramine) require prior authorization. Will be covered in three month increments if >3% weight loss occurs for a maximum of one year.
‐ Eligibility Criteria: To receive weight loss drugs an individual must be at least 12 years old and:
‐ have a diagnosis of BMI > 35 for Orlistat or
>27 for Sibutramine, or
‐ if co-morbidity present, the requisite BMI is
>30 for Orlistat, or >27 for Sibutramine;
‐ documented participation in a weight loss program (including diet and exercise); and
‐ at least two previous attempts at weight loss along with a clinical reason for their failure
» Surgical Coverage
– Covered Procedures: Gastric bypass requires written justification and prior authorization through form
719A (the specific criteria for requesting gastric bypass surgery is unavailable).

CALIFORNIA
Medications indicated to induce weight loss in obese individuals are covered by
Medi-Cal with a showing of medical necessity.
Xenical and Meridia require prior authorization and will be covered in three month intervals if patient sustains >3% weight loss for a maximum of one year.
Eligibility: Individual must be at least 12 years old and have
1) BMI >35 for Xenical; BMI
>27 for Meridia; or
2) If co-morbidity is present,
BMI >30 for Xenical and
BMI > 27 for Meridia
3) Documented participation in weight loss program
(including diet & exercise)
4) At least two previous attempts at weight loss with documented clinical reason for failure
Antiobesics and anorexiants are
excluded with the exception of lipase inhibitors limited to obese individuals with:
1) BMI ≥27 and <30 with comorbidities of hypertension, diabetes or dyslipidemia;
2) BMI ≥30 without comorbidities
Medicaid will not cover more than a 90-day supply of these medications.

Christine Ferguson
Professor
George Washington University
School of Public Health and Health Services
Department of Health Policy
Director, STOP Obesity Alliance