Medicaid

Social Security Act Section 1927 (d)(2) and Texas Administrative Code section 354.1923 allow HHSC to prohibit or restrict coverage of weight management drugs. HHSC provides coverage for certain weight management drugs for Medicaid. Specific coverage exceptions for weight management drugs include appetite stimulants, anorexic agents, and fat absorption-decreasing agents.

Weight management drugs (excluding specific coverage exceptions) are not covered for clients enrolled in traditional Medicaid who are 21 years and over. Claims will reject with NCPDP error code 75 and include the message “Prior Authorization not on file. Contact Pharmacy Benefits Access” in the “Additional Message Information” field (526-FQ). HHSC clinician staff determine coverage, and no form is required.