Indiana Medicaid, administered by the Family and Social Services Administration (FSSA) through programs like Hoosier Healthwise and the Healthy Indiana Plan (HIP), provides health coverage to eligible residents. Coverage for prescription drug classes, including anti-obesity medications, is highly regulated and depends on the state’s drug formulary and the specific plan a recipient is enrolled in. Due to this complex structure, the answer to whether weight loss medication is covered is not a simple yes or no for every recipient.
Current Coverage Status for Anti-Obesity Medications
Indiana Medicaid generally excludes coverage for medications prescribed solely for weight loss for adult members. State administrative code specifically lists “anorectics or any agent used to promote weight loss” as an exception to the drugs covered by the Indiana Health Coverage Programs (IHCP). This policy means that newer, brand-name GLP-1 agonists approved by the Food and Drug Administration (FDA) only for chronic weight management, such as Wegovy or Zepbound, are typically not covered for adults with obesity alone.
Coverage status shifts for members under the age of 21 due to the federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Under EPSDT, Indiana Medicaid may cover FDA-approved weight loss medications, including certain GLP-1 agonists like semaglutide (Wegovy) and liraglutide (Saxenda), if medical necessity is determined case-by-case. For all members, if a GLP-1 agonist is prescribed for a non-weight-loss, FDA-approved use, such as Type 2 diabetes, it is generally covered under the standard pharmacy benefit.
Coverage for any medication is also dependent on the Managed Care Entity (MCE), such as Anthem, MDwise, or MHS, that the recipient is enrolled with. These MCEs manage their own formularies but must adhere to the state’s Statewide Uniform Preferred Drug List (SUPDL) and its exclusions. The exclusion of anti-obesity drugs for adults remains a barrier for low-income individuals affected by obesity.
Prior Authorization and Patient Eligibility Requirements
Even when weight management medication is covered, a rigorous Prior Authorization (PA) process is mandatory. This process ensures that prescribing is clinically appropriate and meets strict administrative hurdles. For members under 21, the PA request must include a diagnosis of morbid obesity with co-morbid conditions and thorough documentation of previous weight loss efforts.
The documentation must confirm that nutritional counseling, structured weight-loss programs, or other pharmacological agents have been attempted and failed before the newer medication is approved. Failure to meet these specific clinical criteria, often set by the MCEs, will result in a denial of coverage.
Non-Pharmacological Treatments Covered by Indiana Medicaid
While pharmacological coverage is highly restricted, Indiana Medicaid provides coverage for alternative, non-drug treatments for obesity. Bariatric surgery, including procedures like laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass, is covered for most members who meet specific eligibility requirements. These requirements include a diagnosis of morbid obesity, typically defined as a Body Mass Index (BMI) of 40 or greater, or a BMI of 35 or greater with a co-morbid condition like Type 2 diabetes or severe sleep apnea.
Adult patients must also provide documentation of a failed physician-supervised, non-surgical weight-loss program lasting at least six consecutive months within the last two years. A mandatory psychological evaluation by a licensed behavioral health provider is required to assess the patient’s understanding and commitment to the long-term lifestyle changes necessary after surgery. For members enrolled in the Healthy Indiana Plan (HIP), only those in the HIP Plus or HIP State Plan benefit packages are eligible for bariatric surgery coverage; HIP Basic members are excluded.
Intensive Behavioral Therapy (IBT) and nutritional counseling are also covered services. Participation in these programs is often a prerequisite for surgical or medication approval. Nutritional counseling is covered for children and adolescents under the EPSDT program, and adult coverage for IBT is available, though it may not be specifically coded for obesity treatment.