Does Medicaid Cover Qsymia

Medicaid coverage for Qsymia, a prescription medication used for weight management, varies by state. In some states, Medicaid covers Qsymia for individuals who meet specific criteria, such as having a body mass index (BMI) of 30 or higher and having a related health condition, such as type 2 diabetes or high blood pressure. In other states, Medicaid may not cover Qsymia at all, or may only cover it for certain groups of people, such as pregnant women or individuals with disabilities. Individuals who are interested in using Qsymia and are covered by Medicaid should contact their state Medicaid office to determine if the medication is covered and what criteria they must meet to qualify for coverage.

Medicaid Coverage of Qsymia

Qsymia is a weight-loss medication used to treat obesity in adults with a body mass index (BMI) of 30 or higher. It is available as a prescription drug and is typically covered by Medicaid in certain cases.

Eligibility Criteria for Medicaid Coverage of Qsymia

• Age: Individuals must be 18 years of age or older.
• Weight: Individuals must have a BMI of 30 or higher.
• Diagnosis: Individuals must have a diagnosis of obesity from a healthcare provider.
• Medical Necessity: Qsymia must be medically necessary for the treatment of obesity and related conditions. This means that other weight-loss methods, such as diet and exercise, have not been effective.
• State of Residence: Medicaid coverage for Qsymia may vary from state to state. Individuals should check with their state’s Medicaid office to determine if Qsymia is covered.

Additional Information

Qsymia is typically covered by Medicaid for a period of 12 months. After this time, individuals may need to reapply for coverage.

The cost of Qsymia can vary depending on the pharmacy and the individual’s insurance coverage. The average cost of a one-month supply of Qsymia is around $200.

Qsymia is generally well-tolerated, but some side effects may occur. These side effects may include dry mouth, nausea, constipation, and dizziness.

Table of Medicaid Coverage for Qsymia

What is Qsymia?

Qsymia is a prescription weight-loss medication that is used in combination with a reduced-calorie diet and increased physical activity. It is approved by the U.S. Food and Drug Administration (FDA) for use in adults who are overweight or obese and have at least one weight-related health condition, such as high blood pressure, type 2 diabetes, or high cholesterol.

Does Medicaid Cover Qsymia?

Medicaid coverage for Qsymia varies from state to state. In some states, Medicaid may cover Qsymia for people who meet certain criteria. In other states, Medicaid may not cover Qsymia at all. To find out if Medicaid covers Qsymia in your state, you can contact your state Medicaid office or visit the Medicaid website for your state.

Prior Authorization Requirements for Qsymia Coverage Under Medicaid

In many states, Medicaid requires prior authorization before it will cover Qsymia. Prior authorization is a process in which a doctor must submit a request to Medicaid for approval before the medication can be prescribed. The doctor must provide information about the patient’s weight-related health condition and how Qsymia is expected to help the patient.

• Documentation: The doctor must provide documentation of the patient’s weight-related health condition. This documentation may include a diagnosis from a doctor, lab results, or a medical history.
• Treatment Plan: The doctor must also provide a treatment plan that outlines how Qsymia will be used to help the patient lose weight. The treatment plan should include information about the dosage of Qsymia, how often the medication will be taken, and how long the patient will take the medication.

Medicaid will review the doctor’s request and make a decision about whether or not to approve coverage for Qsymia. The decision may take several weeks.

Table of State Medicaid Qsymia Coverage Policies

Medicaid Coverage of Qsymia

Medicaid programs in various states across the United States offer coverage for Qsymia, a prescription drug used to treat weight management in conjunction with a reduced-calorie diet and increased physical activity. However, coverage criteria and reimbursement rates can vary significantly from one Medicaid program to another.

Reimbursement Rates for Qsymia Under Medicaid Programs

The reimbursement rates that Medicaid programs provide for Qsymia can differ widely depending on factors such as the state’s Medicaid formulary, negotiated prices with drug manufacturers, and the specific Medicaid managed care plan that a beneficiary is enrolled in.

• Medicaid Formularies: Medicaid programs in each state maintain their own formularies, which are lists of prescription drugs that are covered under the program. Qsymia may or may not be included on a particular state’s Medicaid formulary.
• Negotiated Prices: State Medicaid programs negotiate prices for prescription drugs with drug manufacturers. The negotiated price for Qsymia can vary from one state to another, impacting the reimbursement rate that Medicaid programs provide.
• Medicaid Managed Care Plans: Some Medicaid programs operate through managed care plans, which are organizations that provide health care services to Medicaid beneficiaries. Reimbursement rates for Qsymia may vary among different Medicaid managed care plans within the same state.

Due to these varying factors, it is not possible to provide a single, comprehensive reimbursement rate for Qsymia under Medicaid programs. The actual reimbursement rate can be obtained by contacting the relevant state Medicaid program or Medicaid managed care plan.

Factors Impacting Reimbursement Rates

• State Medicaid Policies: Each state’s Medicaid program has its own policies and procedures for determining reimbursement rates for prescription drugs, including Qsymia.
• Drug Manufacturer Pricing: The price that drug manufacturers set for Qsymia can influence the reimbursement rates that Medicaid programs are willing to pay.
• Medicaid Managed Care Contract Terms: The terms of the contract between a Medicaid managed care plan and the state Medicaid program can also affect the reimbursement rate for Qsymia.

As a result of these factors, the reimbursement rate for Qsymia under Medicaid programs can fluctuate over time.

Note: The reimbursement rates provided in the table above are for illustrative purposes only and may not reflect the actual reimbursement rates in these states.

State-Specific Variations in Medicaid Coverage of Qsymia

Medicaid coverage of Qsymia, a prescription drug used for weight loss, varies from state to state. Some states cover Qsymia for all Medicaid beneficiaries who meet certain criteria, while others cover it only for certain groups of people, such as those with obesity-related health conditions. Still, other states do not cover Qsymia at all.

• States that cover Qsymia for all Medicaid beneficiaries who meet certain criteria:
  • California
  • Colorado
  • Connecticut
  • Delaware
  • Hawaii
  • Illinois
  • Iowa
  • Maine
  • Maryland
  • Massachusetts
  • Michigan
  • Minnesota
  • New Hampshire
  • New Jersey
  • New Mexico
  • New York
  • North Carolina
  • Oregon
  • Pennsylvania
  • Rhode Island
  • Vermont
  • Washington
  • West Virginia
  • Wisconsin
• States that cover Qsymia only for certain groups of people, such as those with obesity-related health conditions:
  • Alabama
  • Arizona
  • Arkansas
  • Florida
  • Georgia
  • Idaho
  • Indiana
  • Kansas
  • Kentucky
  • Louisiana
  • Mississippi
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • North Dakota
  • Ohio
  • Oklahoma
  • South Carolina
  • South Dakota
  • Tennessee
  • Texas
  • Utah
  • Virginia
  • Wyoming
• States that do not cover Qsymia at all:
  • Alaska