Non-Formulary Requests for Obesity Control Drugs

Date: April 28, 2023
 
Attention: All Providers

Effective Date: March 1, 2023

Call to action: Texas Children’s Health Plan (TCHP) would like to let providers know that effective March 1, 2023, the Health and Human Services Commission (HHSC) will no longer approve medically necessary non-formulary drug requests for obesity control drugs for individuals 21 years and older. This aligns with the Social Security Act, Section 1905, since coverage of these drugs is not included in the Medicaid State Plan. The drugs excluded from coverage include, but are not limited to Contrave, Imcivree, Qysmia, Saxenda and Wegovy.

How this impacts providers: Effective March 1, 2023, TCHP will no longer approve medically necessary non-formulary drug requests for obesity control drugs for individuals 21 years and older. If a member is less than 21 years old, a non-formulary request can still be requested for approval for these drugs.

Next steps for providers: Prescribers should share this communication with their staff. We encourage you to work with your patients to explore alternative treatment options for obesity control agents that may be covered under their insurance plan or are available on the formulary.

Note: Refer to UMCM Chapter 2.2, Section VI.I, for the VDP non-formulary request process. HHSC will review coverage for products in this class later this year to determine if these drugs can be added to the formulary.

If you have any questions, please email TCHP Pharmacy at: tchppharmacy@texaschildrens.org.

For access to all provider alerts,log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.