Wegovy is a weight-loss medication used to treat obesity in adults. It is a prescription drug that is not covered by Medicaid in all states. As of 2023, North Carolina Medicaid does not cover Wegovy. This means that people who are enrolled in Medicaid in North Carolina will have to pay for Wegovy out-of-pocket. The cost of Wegovy can vary depending on the dosage and the pharmacy where it is purchased. Without insurance, the average cost of a month’s supply of Wegovy is around $1,300.
North Carolina Medicaid Coverage Guidelines
Medicaid in North Carolina provides comprehensive healthcare coverage to low-income individuals, families, children, pregnant women, elderly adults, and people with disabilities. The program covers a wide range of healthcare services, including doctor’s visits, hospital stays, prescription drugs, dental care, and vision care. However, Medicaid does not cover all healthcare services, and there are some restrictions on coverage for certain services.
One of the medications that is not covered by North Carolina Medicaid is Wegovy. Wegovy is a prescription drug that is used to treat obesity. It is a once-weekly injection that helps people to lose weight by reducing their appetite and increasing their metabolism. Wegovy is a brand-name drug, and there is no generic alternative available. As a result, the cost of Wegovy can be quite high.
Because Wegovy is not covered by North Carolina Medicaid, people who are enrolled in the program and who need to take Wegovy will have to pay for the medication out of pocket. The cost of Wegovy can vary depending on the dosage and the pharmacy where it is purchased. However, the average cost of Wegovy is around $1,300 per month.
There are a few exceptions to the rule that Wegovy is not covered by North Carolina Medicaid. For example, Medicaid may cover Wegovy if the person has a diagnosis of type 2 diabetes and their body mass index (BMI) is 30 or higher. Additionally, Medicaid may cover Wegovy if the person has a diagnosis of Prader-Willi syndrome.
If you are enrolled in North Carolina Medicaid and you need to take Wegovy, you should talk to your doctor about your options. Your doctor may be able to help you find a way to get Wegovy covered by Medicaid, or they may be able to prescribe you a different medication that is covered by Medicaid.
In addition to the information above, here are some additional details about North Carolina Medicaid coverage guidelines:
- Medicaid coverage is available to North Carolina residents who meet certain income and asset limits.
- Medicaid coverage is also available to certain groups of people, regardless of their income or assets. These groups include children, pregnant women, elderly adults, and people with disabilities.
- Medicaid coverage includes a wide range of healthcare services, including doctor’s visits, hospital stays, prescription drugs, dental care, and vision care.
- There are some restrictions on coverage for certain services. For example, Medicaid does not cover cosmetic surgery or elective procedures.
- People who are enrolled in Medicaid can choose to receive their care from a variety of providers, including doctors, hospitals, and clinics.
| Dosage | Average Cost |
|---|---|
| 0.25 mg | $1,250 |
| 0.5 mg | $1,300 |
| 1 mg | $1,350 |
| 1.7 mg | $1,400 |
| 2.4 mg | $1,450 |
Eligibility Requirements for Wegovy Coverage Under NC Medicaid
Wegovy is a prescription weight-loss medication covered by Medicaid in North Carolina. However, coverage is subject to specific eligibility requirements and criteria.
To be eligible for Wegovy coverage under NC Medicaid, individuals must meet the following criteria:
1. Age and Weight Requirements:
- Individuals must be 18 years of age or older.
- They must have a body mass index (BMI) of 30 or higher, or a BMI of 27 or higher with at least one weight-related comorbidity, such as hypertension, type 2 diabetes, or sleep apnea.
2. Medical Necessity:
- Wegovy must be deemed medically necessary by a healthcare provider, who must document the patient’s weight-related health risks and the potential benefits of Wegovy.
- The prescribing provider must also consider other weight-loss approaches, such as diet and exercise, before prescribing Wegovy.
3. Prior Authorization:
- Prior authorization from NC Medicaid is required before Wegovy can be covered.
- To obtain prior authorization, healthcare providers must submit a detailed medical history of the patient, including their BMI, weight-related comorbidities, and previous weight-loss attempts.
4. Income and Asset Limits:
- Individuals must meet the income and asset limits set by NC Medicaid to be eligible for coverage.
- Income and asset limits vary depending on household size and composition.
It’s important to note that eligibility requirements for Wegovy coverage under NC Medicaid may change over time. Individuals should contact their local Medicaid office or consult the NC Medicaid website for the most up-to-date information.
Additionally, coverage for Wegovy may vary among different Medicaid managed care plans. Individuals should check with their specific managed care plan to confirm coverage and any additional requirements or restrictions.
| Eligibility Criteria | Requirement |
|---|---|
| Age | 18 years or older |
| Body Mass Index (BMI) | BMI of 30 or higher, or BMI of 27 or higher with a weight-related comorbidity |
| Medical Necessity | Must be deemed medically necessary by a healthcare provider |
| Prior Authorization | Required before coverage |
| Income and Asset Limits | Must meet NC Medicaid income and asset limits |
Covered Expenses
North Carolina Medicaid covers the following expenses related to Wegovy:
- Medication costs: Medicaid will cover the cost of Wegovy, including the initial prescription and any refills.
- Doctor’s visits: Medicaid will cover the cost of doctor’s visits related to Wegovy, including visits to discuss the medication, monitor its effectiveness, or adjust the dosage.
- Lab tests: Medicaid will cover the cost of lab tests related to Wegovy, such as blood tests to monitor liver and kidney function.
Limitations
There are some limitations to Medicaid coverage for Wegovy:
- Prior authorization: Wegovy requires prior authorization from Medicaid before it can be covered. This means that your doctor will need to submit a request to Medicaid for approval before you can start taking the medication.
- Copayment: Medicaid may require you to pay a copayment for Wegovy. The amount of the copayment will vary depending on your income and the type of Medicaid coverage you have.
- Coverage restrictions: Medicaid may have restrictions on who is eligible for coverage for Wegovy. For example, Medicaid may only cover Wegovy for people who have certain underlying medical conditions.
| Expense | Covered | Limitations |
|---|---|---|
| Medication costs | Yes | Prior authorization required, copayment may apply |
| Doctor’s visits | Yes | Copayment may apply |
| Lab tests | Yes | Copayment may apply |
How to Apply for Medicaid Coverage
To apply for Medicaid coverage in North Carolina, you can use one of these methods:
- Apply online through the NC Medicaid application portal
- Apply in person at your local Department of Social Services (DSS) office
- Apply by mail by downloading and completing the Medicaid application form and mailing it to the address listed on the form
You may also contact the Medicaid customer service line at 1-888-245-0023 for assistance with your application.
Eligibility for Medicaid Coverage
To be eligible for Medicaid coverage in North Carolina, you must meet certain eligibility requirements, including:
- Being a resident of North Carolina
- Being a U.S. citizen or a qualified non-citizen
- Meeting income and asset limits
Income and Asset Limits
The income and asset limits for Medicaid coverage in North Carolina vary depending on your household size and composition. For a single person, the income limit is 138% of the federal poverty level (FPL), and the asset limit is $2,000. For a family of four, the income limit is 250% of the FPL, and the asset limit is $3,000.
| Household Size | Income Limit (% of FPL) | Asset Limit |
|---|---|---|
| 1 | 138% | $2,000 |
| 2 | 200% | $3,000 |
| 3 | 250% | $4,000 |
| 4 | 250% | $5,000 |
If you meet the income and asset limits, you may still be eligible for Medicaid coverage if you are pregnant, disabled, or have a child under the age of 19.
Applying for Medicaid Coverage
To apply for Medicaid coverage in North Carolina, you will need to provide the following information:
- Your Social Security number
- Your birth certificate
- Proof of residency in North Carolina
- Proof of income and assets
- Information about your household members
You may also be asked to provide additional information, such as proof of disability or pregnancy.
Contact Information
If you have any questions about Medicaid coverage in North Carolina, you can contact the Medicaid customer service line at 1-888-245-0023.
Hey everyone, thanks for sticking with me till the end of this wild ride! I know this topic can be a bit of a head-scratcher, but I hope I’ve managed to shed some light on whether or not Nc Medicaid covers Wegovy. If you still have questions, feel free to drop me a line – I’m always here to help. And don’t forget to come back again soon for more exciting discussions and insights. Take care, and have a groovy day!