Insurance Coverage for Weight Loss Medication: When Will It Happen

Insurance companies have been slow to cover weight loss medications, but change is on the horizon. As of 2022, some insurance providers have started to include weight loss medications in their coverage.

Many people struggle to afford these medications out of pocket, and insurance coverage would be a game-changer. According to recent reports, some insurance companies are expected to cover weight loss medications by 2024.

The FDA has approved several weight loss medications in recent years, including semaglutide and tirzepatide. These medications have been shown to be effective in helping people lose weight and improve their overall health.

Insurance companies tend not to cover weight loss medications, considering them a cosmetic need rather than a medical one. However, some plans may cover certain medications with prior authorization.

The American Medical Association (AMA) disagrees with this stance, officially calling obesity a disease. They urge all payers to ensure coverage parity for evidence-based treatment of obesity, including FDA-approved medications without exclusions or additional carve-outs.

Obesity is linked to cardiovascular and other related diseases, which could lead to cost savings for payers over time. Research shows that treating obesity helps to prevent diabetes and heart disease.

Medicare is prohibited by law from covering weight loss medications, but the Treat and Reduce Obesity Act of 2023 aims to change this. If passed, it would allow Medicare to cover weight loss medications.

Some states cover weight-loss medication in their Medicaid programs, but this varies widely. According to a 2022 Urban Institute analysis, fee-for-service Medicaid only covers weight-loss medication in 15 states.

Coverage of weight-loss medications depends on the reason why the drug is being prescribed, as well as the state where the person lives and their coverage type.

To qualify for weight loss medication, you typically need to have a high Body Mass Index (BMI). A BMI of 30 or greater qualifies you for most medications, but some medications are also approved for people with a BMI of 27 or greater with comorbidities like diabetes or high blood pressure.

Age is also a factor, with most medications approved for adults, but some are being studied for use in adolescents.

Some medications, like Zepbound, are only approved for adults, while others, like Phentermine, are approved for adolescents 16 and older.

Your doctor will assess your overall health and consider the potential benefits and risks of the medication before prescribing it.

If you haven't lost at least 5% of your body weight after taking the medication for 3 to 6 months, your doctor may switch you to a different drug.

To qualify for prescription weight loss pills, your BMI is a key factor, with the following criteria:

Keep in mind that Medicaid coverage for weight loss medications varies by state, with some states covering these drugs and others not.

Commercial insurers tend to not cover weight loss medications, considering them a cosmetic need rather than a medical one. This is the case for many employer-sponsored health plans as well.

Medicare is prohibited by law from covering weight loss medications, but Medicare Part D may cover them if prescribed for another condition like diabetes. This is an exception to the general rule.

Self-insured employer-sponsored health plans, which cover the majority of people with employer-sponsored health insurance, vary considerably from one to another and may cover weight-loss medications depending on the employer's approach.

Insurance companies can be quite stubborn when it comes to covering weight loss medications. Many insurers and employers consider weight loss a cosmetic need rather than a medical one, which is why they often don't cover these medications.

The American Medical Association (AMA) disagrees, having officially called obesity a disease in 2010. They consider weight loss drugs a medical treatment and are urging all payers to ensure coverage parity for evidence-based treatment of obesity.

The AMA's stance is backed by research showing that treating obesity helps to prevent diabetes and heart disease. This preventative approach could save money for payers over time, but it's not being taken into account by many insurers.

The Treat and Reduce Obesity Act of 2023 aims to change this by allowing Medicare to cover weight loss medications. The Congressional Budget Office (CBO) estimates that passage of this act would increase costs for anti-obesity medications, but reduce federal costs for other related health issues.

In 2003, Medicare was prohibited from covering weight loss medications due to past safety concerns. This law was enacted in response to the fen-phen scandal in the 1990s.

Employer-sponsored health plans can be complex, but it's essential to understand how they work. Self-insured plans, which cover the majority of people with employer-sponsored health insurance, are designed by the employer and regulated under ERISA.

These plans vary considerably from one to another, and coverage of weight-loss drugs will depend on each specific employer's approach. Some employer-sponsored health plans cover weight-loss medications, even if the patient doesn’t have diabetes or cardiovascular disease.

The specifics of coverage will depend partly on whether the plan is self-insured, or purchased by the employer in the large-group or small-group market. Plans in the small-group market have to provide at least the same benefits as the EHB benchmark plan.

Only about a quarter of employer-sponsored health plans cover GLP-1 drugs for weight loss, although the majority do cover them for the treatment of diabetes. The North Carolina State Employee Health Plan recently opted to stop covering GLP-1 agonist medications for members who do not have diabetes.

The Growing Popularity of weight loss medication is a trend worth noting. Sales of semaglutide, including Ozempic and Wegovy, totaled $10.7B in 2021.

Celebrity endorsements have contributed to the surge in interest. Oprah Winfrey, Tracy Morgan, and Amy Schumer are among the notable figures who have spoken highly of GLP-1 agonists.

Prescriptions for semaglutide increased by 300% from 2020 to 2022. This is a significant jump in a short period of time.

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

Wegovy, Saxenda, and Zepbound are three GLP-1 drugs FDA-approved for weight management. These medications work by reducing appetite and slowing digestion, which can lead to significant weight loss.

If you have a BMI of 30 or higher, or a BMI of 27 or higher with another health condition, your doctor may prescribe these medications. However, insurance coverage varies, and some employer plans may cover them for weight loss.

Wegovy is also approved for adults with cardiovascular disease who are overweight. Mounjaro, another medication, is being investigated for weight loss, but it's currently only FDA-approved for diabetes treatment.

Orlistat, a lipase inhibitor, works differently by preventing fat absorption in the gastrointestinal tract. It's available over-the-counter as Alli and by prescription as Xenical.

Common side effects of these medications include nausea, constipation, and diarrhea. Serious side effects are rare but possible, so it's essential to discuss the pros and cons with your healthcare provider.

Here are some FDA-approved weight loss medications:

Each medication works differently, so it's crucial to understand how they function and their potential side effects.

The high cost of weight loss medications is a significant barrier for many people. A month's supply of Wegovy (semaglutide) can cost around $1,300, with similar prices for Zepbound (tirzepatide) and Saxenda (liraglutide).

Insurance often doesn't cover these medications, making it difficult for patients to afford them. However, there are some options available to help reduce the financial burden.

Some medications, like Orlistat (Xenical and Alli), are cheaper but less effective. A month's supply of Orlistat can cost around $50-$100.

Patient assistance programs can provide discounted pricing or even free medications, depending on income and insurance status. Manufacturer programs, such as those offered by Novo Nordisk for Saxenda and Wegovy, can be a good starting point.

GoodRx offers discounted prices on various medications, including weight loss drugs. By using GoodRx coupons, patients can significantly reduce their out-of-pocket costs.

Medicare Part D Extra Help can assist with prescription drug costs, but it typically doesn't cover weight loss medications. Generic alternatives, like bupropion, liraglutide, or orlistat, can be a more affordable option.

Here's a breakdown of the estimated monthly costs of some weight loss medications:

Comparison shopping and using coupons can also help patients save money. Pharmacies like Westmont Pharmacy may offer their own discount programs or work with patients to find affordable solutions.

Many patients struggle to afford weight loss medications, but there are ways to make them more accessible.

First, check the FDA Drug Shortages List to ensure the medication is available for reliable refills.

You can also consider generic versions of older drugs, such as bupropion, liraglutide, or orlistat, which are often cheaper.

GoodRx is a service that lets patients compare prices across pharmacies and look for coupons, which can significantly reduce out-of-pocket costs.

Manufacturer Programs, such as those offered by Novo Nordisk for Saxenda and Wegovy, can provide medications at a reduced cost or even for free, depending on income and insurance status.

Medicare Part D Extra Help can assist with prescription drug costs, but it typically doesn't cover weight loss medications, so it might only help with related diabetes medications.

Pharmacies like Westmont Pharmacy may offer their own discount programs or work with patients to find affordable solutions, so it's always worth asking your pharmacist about any available discounts or assistance programs.

More than two out of three adults in America are overweight, and over a third are obese. This has led to a greater interest in effective treatments for weight loss.

Many health insurance plans don't routinely cover weight loss medications unless you have other medical conditions tied to obesity.

Obesity and overweight have become significant health concerns in America, sparking a surge in interest in treatments like weight loss medications.

The high cost of these medications can be a hurdle, even with promising results in helping people lose weight.

Given the inconsistent insurance coverage and high costs, it's vital to understand your health plan's policies and explore all available options.

Advocating for yourself can sometimes lead to coverage, so it's worth taking the time to navigate your insurance plan.

Your doctor plays a crucial role in determining if you're a good candidate for weight loss prescription medication. They'll assess your medical history, including any previous attempts at weight loss, and evaluate any health challenges that might make it difficult for you to lose weight.

Your doctor will review your medical history to understand your past attempts at weight loss. This is an important step in determining if prescription weight loss pills are right for you.

Age is also a factor in determining eligibility for weight loss prescription medication. Generally, these medications are not recommended for pregnant or breastfeeding women. Your age and overall health will influence your doctor's decision.

To qualify for a prescription weight loss pill, you typically need to meet specific BMI criteria. For most medications, this means having a BMI over 30, or over 27 if you have obesity-related conditions such as cardiovascular disease or diabetes.

Here are the key BMI criteria for qualifying for weight loss prescription medication:

Your doctor will also assess your overall health, including any existing health problems, to determine the potential benefits and risks of the medication. They'll discuss the pros and cons of different medications with you, including potential side effects like nausea, constipation, and diarrhea.