Does Insurance Cover Weight Loss Injections and What Are Your Options?

Insurance coverage for weight loss injections can be a bit of a mystery, but we've got the lowdown. Many insurance plans cover semaglutide injections, such as Ozempic, for weight loss when prescribed for type 2 diabetes.

Some insurance plans may require a prior authorization or step therapy before covering these injections. This means you may need to try other weight loss methods first or have your doctor justify why you need semaglutide.

If your insurance doesn't cover semaglutide injections, you may be able to appeal the decision or consider alternative weight loss treatments.

Weight loss injections are a type of medication that helps control blood sugar levels and reduce appetite, making it easier to lose weight.

These injections are part of a class of drugs known as GLP-1 receptor agonists, which also slow digestion and promote a feeling of fullness.

They're prescribed to individuals with a BMI of 30 or higher, or to those with a BMI of 27 or higher who have obesity-related conditions like hypertension or type 2 diabetes.

Clinical studies have shown that patients using these medications can lose up to 15-20% of their body weight in the first year of treatment.

For many people, these injections represent a breakthrough in weight loss treatment, offering a level of success that traditional diet and exercise programs often fail to provide.

The cost of these injections can be a financial challenge, ranging from $900 to $1,300 per month without insurance.

Insurance coverage for weight loss injections is not a one-size-fits-all situation. It largely depends on your insurance plan and the specific medication you're prescribed.

UnitedHealthcare, for example, has coverage for most major weight loss drugs, including Ozempic, Mounjaro, Wegovy, and Rybelsus. They also offer free online health and weight loss coaching.

However, not all insurance plans cover weight loss injections. Some insurers may view them as cosmetic rather than medically necessary, leading to denials. According to the National Association of Insurance Commissioners (NAIC), insurance companies often require patients to meet specific eligibility criteria before they will cover these medications.

To qualify for coverage, you may need to have a BMI of 30 or above (or 27 with related health conditions) and proof that you've tried other weight loss methods without success. Even with these criteria met, you may still face denials.

Here's a breakdown of some insurance providers' coverage for weight loss medications:

Keep in mind that coverage requirements and limitations can vary widely depending on your specific insurance plan. It's essential to check the details of your plan to understand what's covered and what's not.

Some popular weight loss medications include Ozempic, Wegovy, and Mounjaro. Ozempic costs $969 per month without insurance and $291 per month with insurance. Wegovy is approved for weight loss in people with a BMI of 30 or higher, or with a BMI of 27 or higher and at least one weight-related health issue.

The cost of Mounjaro with insurance is about $321 per month, which is $3,849 per year. However, prescription benefits vary widely, and you may be able to get a Mounjaro coupon through the drug maker's Mounjaro Savings Card program to save up to $150 per month.

Here's a brief rundown of these medications and their costs:

Generic semaglutide costs about $300 per month through a compounding pharmacy. This is significantly cheaper than the brand-name Ozempic.

Generic semaglutide is about one-third of the price of brand-name Ozempic. This makes it an attractive option for those looking to save money on their medication.

Your local pharmacy won't sell generic Ozempic because it hasn't been approved. This means you'll need to find a compounding pharmacy that can mix their own prescriptions.

The FDA has issued a warning about compounded semaglutide. They say the drugs you receive could contain wrong ingredients, incorrect amounts of semaglutide, or harmful additives.

Mounjaro and Zepbound are two brand names for the drug tirzepatide. The cost of tirzepatide averages $1,064 per month if you don't have insurance coverage.

Mounjaro costs about $9 more per month than Zepbound. This means that if you're considering these two options, you'll pay $1,073 per month for Mounjaro without insurance, compared to $1,064 for Zepbound.

Mounjaro is a popular weight loss medication that has gained attention in recent years. It's an FDA-approved diabetes drug that Lilly is investigating using for weight loss. Mounjaro costs $1,069 per month if you pay full price or $321 per month if you have insurance coverage.

A discount from the drug maker, Lilly, can bring the cost down to about $171 per month with insurance. Mounjaro is also available with a prescription benefits program that can make it more affordable.

If you're uninsured, Mounjaro costs $12,829 per year without insurance, but you can use a GoodRx coupon to save between 7% and 25% off the full retail price. Alternatively, you could ask your doctor for free samples of Mounjaro.

Here's a breakdown of the costs associated with Mounjaro:

It's worth noting that the cost of Mounjaro can vary depending on your insurance plan, with some plans offering a $25 copay or requiring you to pay up to 50% of the cost.

The sales of semaglutide, including Ozempic and Wegovy, totaled $10.7 billion in 2021.

Sales of semaglutide prescriptions increased by 300% from 2020 to 2022. This significant jump is a major contributor to the growing popularity of weight loss medications.

The sales of anti-obesity medications stood at $1.1 billion for the second quarter of 2023, a 65 percent increase over the previous quarter.

Celebrity endorsements have played a significant role in fueling public interest in these medications, with notable figures like Oprah Winfrey, Tracy Morgan, and Amy Schumer speaking in favor of GLP-1 agonists.

Insurance companies have varying policies when it comes to covering weight loss injections. Some, like Kaiser Permanente, may only cover the injections if you've tried other methods and have a BMI of 40 or higher. Others, like Blue Cross Blue Shield, may consider weight loss injections as preventive medicine, making them more accessible to those who need them.

Insurance companies also have different requirements for coverage. For example, Aetna may require you to pay for the first three months of weight loss injections yourself and show that you've lost 5% of your body weight before they'll cover the cost. Cigna, on the other hand, may require three months of diet and exercise for weight loss injections to be covered.

Here are some insurance companies that have been known to cover weight loss injections, along with their requirements:

The American Medical Association (AMA) has been a key player in pushing for insurance coverage of weight loss medications. In 2013, the AMA classified obesity as a chronic disease, which marked a significant shift in the medical community's understanding of the condition.

The AMA's stance has been echoed by the Ontario Medical Association (OMA), which also considers obesity a disease. This shared perspective has led to increased pressure on insurance companies to provide comprehensive coverage for weight loss treatments.

The AMA has taken a strong stance on this issue, passing a resolution in November 2023 that urges all payers to ensure coverage parity for evidence-based treatment of obesity. This means that the AMA is advocating for equal coverage of weight loss medications without exclusions or additional carve-outs.

Obesity is a significant risk factor for cardiovascular and related diseases, and treating it can help prevent these conditions. Research has shown that weight loss medications, such as Wegovy, offer cardiovascular benefits and can help prevent diabetes and heart disease.

The U.S. Congress has also taken notice of the importance of treating obesity, with the Treat and Reduce Obesity Act of 2023 aiming to increase coverage of weight loss medications for Medicare recipients. The Congressional Budget Office has estimated that this could significantly affect health care spending and the federal budget.

Blue Cross Blue Shield plans can offer significant savings on weight loss drug coverage, with some plans covering costs before meeting your deductible because they're considered preventive medicine.

You'll need to check your specific plan details, as coverage varies by region and is operated independently by each regional subsidiary.

BCBS plans in California may offer different coverage than those in Louisiana or Massachusetts, so it's essential to research your local options.

Some Blue Cross Blue Shield plans can save you hundreds or thousands of dollars per year on weight loss drug coverage.

Blue Cross Blue Shield plans may cover weight loss drugs before meeting your deductible, considering them as preventive medicine. This can save you hundreds or thousands of dollars per year.

Some Blue Cross Blue Shield plans have a large set of healthy living programs, including apps, coaching, nutrition counseling, and fitness tools. These programs may also offer free WeightWatchers.

Aetna may cover weight loss drugs if you pay for the first three months yourself and show you've lost 5% of your body weight. You can also get free weight loss coaching and discounts on nutrition programs, gym memberships, and home exercise equipment.

Cigna will cover weight loss drugs after initial approval, which can last for four to eight months. To qualify, you'll need to have a BMI that meets their requirements and have lost at least 5% of your body weight.

Kaiser Permanente typically won't cover weight loss drugs when used only for weight loss and you have a BMI less than 40. They may cover the drugs if you've tried two other medications for at least three months each and are on a diet and exercise program.

UnitedHealthcare has coverage for most major weight loss drugs, including Ozempic, Mounjaro, Wegovy, and Rybelsus. They also offer free online health and weight loss coaching.

Here's a list of some insurance companies that offer weight loss drug coverage:

Keep in mind that insurance companies may have different requirements for coverage, such as prior authorization or meeting certain BMI or weight loss requirements. Be sure to check with your insurance provider to see what's covered and what's not.

You can get some weight loss injections for free through certain programs. If you're a U.S. citizen or legal resident with a total household income at or below 400% of the federal poverty line, you might be eligible.

To qualify, you must not have insurance, Medicare, or any other federal, state, or government program such as Medicaid or VA benefits. You also need a diagnosis of type 2 diabetes to qualify for some programs.

You can check your eligibility under the federal poverty guidelines online.

Insurance coverage is not always a guarantee for weight loss injections, but there are alternative ways to reduce costs. Many pharmaceutical companies offer savings cards and patient assistance programs to help patients with out-of-pocket expenses.

You can get Ozempic for $25 per month if you use the Ozempic Savings Program on top of your insurance benefits. This Ozempic coupon is available for free from the drug maker NovoCare, but the $25 per month rate is only available if you have great insurance benefits.

There are cheaper alternatives to Ozempic, such as compounded semaglutide, which is typically much more affordable than brand-name alternatives. For example, Ro offers compounded semaglutide starting at $194 for the first month, and from there, the medication costs $399 monthly.

If you have commercial insurance, you may qualify for the Zepbound savings offer, which brings the cost of a one-month prescription of Zepbound down to $25 (with insurance coverage) or $650 (without insurance coverage). This may be a cheaper option if you're looking for a medication to help with weight loss.

Here's a comparison of the list prices for some popular weight loss medications:

Generic versions of older drugs, such as bupropion, liraglutide, or orlistat, may also be a more affordable option for patients whose insurance won't cover weight loss medications.

Mounjaro costs about $321 per month with insurance, which is a relatively affordable option. You can use the Mounjaro Savings Card program to save up to $150 per month. However, this discount is only available with a private insurance plan, not Medicare or Medicaid.

Medicare and Medicaid can be a bit confusing, but let's break it down simply. If you have Medicaid, some plans cover Ozempic and other GLP-1 drugs, but you'll need to check your state's Medicaid program to see if it's covered under your plan.

To do this, visit your state's Medicaid website and look for information on covered medications. You'll also need to meet certain eligibility requirements, like having a low income. Some medications may require prior authorization from your insurance provider to be covered.

Medicare, on the other hand, covers Ozempic for certain diagnoses, but the cost will depend on your copay and deductible. You can check your plan's formulary to see if Ozempic is covered and what tier it's listed under.

Medicare covers Ozempic for certain diagnoses, including sleep apnea and obesity, but the price you pay will depend on your copay and deductible.

Medicare Part D plans cover Ozempic, and you can check your plan's formulary to see if it's covered and at what tier.

To get Medicare coverage for Zepbound, the FDA must approve it for sleep apnea and obesity, and then Medicare Part D plans will be able to cover it.

Medicare is barred from covering weight loss medication due to past safety concerns, specifically the fen-phen scandal in the 1990s.

You must meet certain eligibility requirements to be covered by Medicaid, such as having a low income, and some medications may require prior authorization to be covered.

Some Medicaid plans cover medications like Ozempic and other GLP-1 drugs, but you'll need to check your state's Medicaid program website to see if it's covered.

If your Medicare plan covers Ozempic but other GLP-1 drugs are listed at a lower cost, your healthcare provider may be able to request an exception to get you a lower copay.

Medicare can cover Ozempic for type 2 diabetes, but you'll need to share documentation of your diagnosis with your Part D plan.

Medicare spent $2.6 billion on Ozempic in 2021 and $4.6 billion in 2022, making it one of the 10 drugs Medicare spends the most on.

Even if the Medicare Plan Finder says Ozempic is covered, you won't qualify if you don't have a type 2 diagnosis.

Some plans require you to try other medications first, and similar rules apply to Mounjaro.

Medicare Part D plans can cover Wegovy for adults with cardiovascular disease and obesity, but very few plans currently cover it.

As of July, very few plans have opted to add Wegovy to their formularies this year.

Plans will decide on prior authorization requirements to show you meet the cardiovascular disease risk.

Zepbound (tirzepatide) is not covered by Medicare because the FDA approved it for weight loss only.