Michigan Medicaid, which includes the Healthy Michigan Plan, provides health coverage to eligible residents. Coverage for prescription weight loss medications is highly restricted and subject to rules set by the federal government and the state’s Department of Health and Human Services (MDHHS). This creates a distinction between drugs approved for weight management and those covered for other medical conditions, even if they share the same active ingredient. Understanding the specific requirements for pharmacological and non-pharmacological therapies is necessary for beneficiaries seeking support.
Michigan Medicaid Coverage Status for Weight Loss Drugs
Michigan Medicaid covers a select list of medications for weight management, managed under strict prior authorization criteria. Many newer, high-cost anti-obesity medications, particularly GLP-1 receptor agonists, are included on the Medicaid Health Plan Common Formulary. This list includes drugs like Wegovy (semaglutide) and Saxenda (liraglutide), which are specifically Food and Drug Administration (FDA) approved for chronic weight management.
The state distinguishes between drugs used exclusively for weight loss and those prescribed for Type 2 diabetes. Medications such as Ozempic or Mounjaro are covered for beneficiaries with a Type 2 diabetes diagnosis, following federal guidelines, even though they result in significant weight reduction. A new state budget directive aims to implement stricter criteria for drugs prescribed solely for obesity, effective January 1, 2026.
Under new restrictions, anti-obesity GLP-1 agonists like Wegovy will be limited exclusively to individuals classified as morbidly obese. Coverage is contingent upon the failure of other weight loss interventions, aiming to prevent the need for higher-cost bariatric surgery. Older medications, including certain appetite suppressants like phentermine and the lipase inhibitor orlistat (Xenical), are also covered but require prior authorization.
Clinical Criteria for Medication Approval
Obtaining coverage for a weight loss medication requires the prescribing provider to submit a Prior Authorization (PA) request to the Medicaid Health Plan. This process requires thorough documentation confirming the patient meets specific clinical thresholds and has attempted other conservative measures.
The standard clinical requirement for adults is a Body Mass Index (BMI) of $30 \text{ kg/m}^2$ or higher. Coverage is also considered for patients with a BMI of $27 \text{ kg/m}^2$ to $29.9 \text{ kg/m}^2$ who have at least one weight-related comorbidity, such as hypertension, Type 2 diabetes, or coronary artery disease. The physician must attest that the requested medication is part of a comprehensive treatment plan, including an exercise regimen and a calorie- and fat-restricted diet.
For some older non-GLP-1 anti-obesity drugs, the PA documentation must detail at least two failed physician-supervised weight loss attempts. The prescribing provider must also confirm that underlying metabolic conditions, such as thyroid dysfunction, have been ruled out or are currently being treated. Continued approval for therapy depends on demonstrating a clinically significant improvement after the medication is initiated.
Covered Non-Pharmacological Weight Management Options
For beneficiaries who do not qualify for pharmacological treatment or require a more aggressive intervention, Michigan Medicaid covers several non-pharmacological options. Bariatric surgery is a covered service when medically necessary for the treatment of obesity. Covered procedures typically include Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding.
Coverage for surgery is approved for individuals with a BMI of $40 \text{ kg/m}^2$ or higher, or a BMI between $35 \text{ kg/m}^2$ and $39.9 \text{ kg/m}^2$ with at least one severe obesity-related co-morbid condition. The prior authorization request must include a psychological evaluation to assess the beneficiary’s ability to comply with necessary post-operative lifestyle changes. Mandatory participation in a pre-operative weight loss regimen is not required for coverage under the Michigan Medicaid program.
The Medicaid program also covers other services essential for managing weight. These services include physician office visits, laboratory testing, and behavioral health interventions. Nutritional counseling and intensive behavioral counseling services are covered as part of a broader array of health services for obesity treatment.
Beneficiary Steps for Coverage Verification and Appeals
Beneficiaries should first verify coverage by consulting the Michigan Department of Health and Human Services (MDHHS) Medicaid Health Plan Common Formulary online. Because the state utilizes a managed care model, patients enrolled in a Medicaid Health Plan (MHP) should also contact their specific plan for the most current coverage details and Prior Authorization requirements.
If a request for a weight loss medication or service is denied, the beneficiary has the right to file an appeal. The first step involves filing a local appeal with the Medicaid Health Plan within 60 calendar days from the date on the denial notice. If the local appeal is unsuccessful, the beneficiary can request a State Fair Hearing with the MDHHS.
To request a State Fair Hearing, the beneficiary must contact the state to receive the necessary hearing request form (DCH-0092). This request must be submitted within 120 calendar days from the date of the notice resolving the local appeal. If the patient wishes to continue receiving the service while the appeal is pending, they must request the continuation of benefits and file the State Fair Hearing request within 10 calendar days of the adverse decision.