Weight loss drugs have been all the rage in recent years, as celebrities and public figures with unattainable figures inspire the masses to embrace ways to get in shape quicker than ever before.
But drugs like Ozempic, Wegovy, Mounjaro, and Zepbound can be expensive, leaving many to wonder if it can be covered by health insurance. While these medications may be covered if they are prescribed for conditions like diabetes, they are less likely to be covered for weight loss alone, but there are no blanket rules. Let’s dive in and find out:
Commonly Prescribed Weight-Loss Drugs
Let’s explore the commonly prescribed weight loss drugs and the categories they are sorted under:
GLP-1 Receptor Agonists
The U.S. Food and Drug Administration (FDA) has approved several glucagon-like peptide-1 receptor agonists (GLP-1 drugs) for the treatment of type 2 diabetes. These drugs, such as Wegovy, Zepbound, and Saxenda, have also been approved for chronic weight management due to their effectiveness in aiding weight loss.
Other GLP-1 Drugs
Other GLP-1 drugs like Mounjaro, Ozempic, Trulicity, and Rybelsus are approved for type 2 diabetes treatment but not specifically for weight management. However, they can still be prescribed off-label for weight loss.
Lipase Inhibitors
Orlistat (marketed as Xenical and over-the-counter as Alli) is another medication used for obesity management. Unlike GLP-1 drugs, Orlistat works by preventing fat absorption in the gastrointestinal tract.
Checking Your Health Insurance To See If It Covers Weight Loss Drugs
If you have been diagnosed with type 2 diabetes, your doctor may prescribe a GLP-1 drug. It's important to check with your health plan to see which drugs are covered, as plans have their own formularies and are not required to cover all drugs within a category.
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For individuals with cardiovascular disease and obesity or overweight, Wegovy may be prescribed to reduce the risk of serious cardiovascular events. Again, verifying if this medication is covered by your health plan is crucial. A call to your providers should be able to offer all the clarification you need.
Obamacare and Weight Loss Drugs
Under the Affordable Care Act (ACA), individual and small-group health plans must cover at least one drug in each category and class as defined by the United States Pharmacopeia (USP). However, the USP guidelines currently do not include categories for weight-loss drugs, meaning these medications are not required to be covered under Essential Health Benefits (EHB) rules. To access weight loss medications, patients must have been diagnosed with a different condition.
Which States Include Weight Loss Medications In Their Benchmark Plans?
Coverage rules for weight-loss medications vary by state. A 2022 Urban Institute analysis found that only North Carolina and New Mexico included coverage of weight-loss medications in their EHB benchmark plans. North Carolina’s plan covers some anti-obesity medications, although not all weight-loss drugs are included.
Will There Be Changes To How Health Insurance Companies Treat Weight Loss Drugs As They Get More Popular?
In a proposed rule published in late 2023, the Department of Health and Human Services (HHS) solicited comments on potentially updating EHB formulary coverage rules to include weight-loss drugs. Although no changes have been finalized, this indicates a potential shift in future coverage.
Do Employer-Sponsored Health Plans Cover Weight Loss Drugs?
Some employer-sponsored health plans do cover weight-loss medications, but the extent of coverage can vary. Self-insured plans, which cover most people with employer-sponsored insurance, are designed by the employer and are not subject to state-level insurance laws. Coverage for weight-loss drugs will depend on the specific employer’s plan.
For employers purchasing coverage in the large-group or small-group markets, the coverage options depend on what insurers offer. In the small-group market, plans must at least match the EHB benchmark plan, which often does not cover weight-loss drugs.
Does Medicare Cover Weight-Loss Drugs?
Medicare does not cover prescription drugs used solely for weight loss. This rule has been in place since the creation of Medicare Part D. However, Medicare Part D can cover these drugs if prescribed for other medical conditions like diabetes or to reduce cardiovascular risk in adults with obesity.
Does Medicaid Cover Weight-Loss Drugs?
Federal Medicaid rules allow states to exclude coverage of weight-loss drugs. A 2022 Urban Institute analysis indicated that only a few states cover weight-loss medications under Medicaid. Coverage depends on whether the drug is prescribed for diabetes or cardiovascular risk reduction, and the specific state’s rules.
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Can I Appeal If My Health Insurance Declines To Cover Weight Loss Drugs?
If your health plan does not cover a specific weight-loss drug, you and your doctor can file an appeal. If the request is denied but other similar medications are covered, you can discuss alternative options with your doctor.
How Much Do Weight-Loss Drugs Cost Out-of-Pocket?
The list prices for weight-loss medications can range from $900 to $1,300 per month. This cost is often prohibitive without insurance coverage. Health plans that do cover these drugs will have varying out-of-pocket costs depending on the formulary tier, copays, coinsurance, and deductibles.
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The Sum-Up:
Coverage for weight-loss drugs like Ozempic, Wegovy, Mounjaro, and Zepbound depends on several factors, including the specific health plan, the reason for the prescription, and state regulations. It is crucial to review your health plan's formulary and consult with your healthcare provider to understand your coverage options.
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