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DMAS will soon be issuing a memo (link here) to notify providers about changes to the Preferred Drug List (PDL).  This bulletin serves as an addendum to that memo -- it does not change the drugs or classes on the PDL (also called the Common Core Formulary) but instead provides notice about upcoming changes to service authorization criteria for certain weight-loss drugs. 

DMAS will continue to honor active authorizations recently approved under its prior weight-loss drug criteria. Future requests and reauthorizations will be subject to the updated criteria outlined here once a new service authorization form is in use.

• Upcoming Criteria for Preferred Weight-Loss Drugs
  • Requirements around patient trial, and failure, of weight loss via comprehensive lifestyle interventions
  • Requirement that providers attest to the patient’s obesity as disability and life threatening (i.e. puts the patient at risk for high morbidity conditions)
  • Requirement that patients try and fail a non-GLP-1 weight loss drug in the previous 6 month before approval of GLP-1 drugs
  • Requirement that patients have a BMI of at least 40 kg/m2, or a BMI of at least 35 kg/m2 and two or more chronic conditions, for approval of GLP-1 drugs
  • Expectations around submission of documentation supporting patients’ completion of service authorization requirements

Obesity is a particularly common and morbid condition among Virginia Medicaid beneficiaries. It affects over 30% of Virginians¹, many of whom experience the most severe class of obesity with a body mass index (BMI) over 40 kg/m2². Obesity has been identified as a driver of multiple severe diseases, including but not limited to: heart disease, diabetes, stroke, arthritis, depression and cancer³. Beyond dietary and physical activity factors, obesity has been increasingly linked to genetic, environmental and social need-related factors³.

Management of obesity is multifaceted. Initial recommended treatment strategies center around comprehensive lifestyle interventions that address patients’ diet, exercise, and behavioral modification. Medication is not a first-line therapy, but can be considered in patients with obesity who fail to achieve sufficient weight loss despite comprehensive lifestyle interventions. Recent pharmaceutical advances, including the expanded approval of GLP-1 drugs, have offered patients and providers additional options. While studies have demonstrated significant weight-loss among carefully selected patients while patients have remained on these drugs, their impact on health long term continues to being studied. 

These changes will ensure appropriate access to and use of approved weight loss pharmacotherapies for FFS and MCO members to support long term health outcomes and ensure alignment with requirements outlined in 12 VAC 30-50-210 (A)(3). For questions on coverage for members enrolled in a managed care organization, refer to the contact information listed below.