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The last few years have seen a proliferation of highly effective and innovative weight loss medications, so it should come as no surprise that many patients are interested in their costs and whether those can be charged to their insurance.
This is nothing new, as through the years, many weight loss medications have created a similar buzz. However, their efficacy was not as strong as the current crop of weight loss injection medications, and many of these older medications have now become available as generics, making them affordable for most people.
The newer weight loss treatments are still considerably expensive, and some of these medications are meant to be taken for very long periods of time. So, the question remains in the minds of many patients: Is weight loss medication covered by insurance?
Who Qualifies For Weight Loss Medication?
Obesity rates continue to rise in the U.S., with some estimating that around 50% of the population is eligible to use weight loss medication.
Generally speaking, insurance companies consider some weight loss medications to be approved for people with obesity and others for patients who are overweight (but not medically obese). Still, having a high BMI (high enough to be classified as overweight or obese) is not sufficient on its own to qualify for weight loss medication.
Another factor affecting the eligibility of weight loss medications to be covered by insurance is if the patient is diagnosed with diabetes. For example, semaglutide (brand name Ozempic) and tirzepatide (brand name Mounjaro) have gotten a lot of hype recently due to their alleged weight-loss effects. However, the FDA has only approved those medications to treat type 2 diabetes; if the patient is not diagnosed with it, insurance will not cover them. For weight loss, drug manufacturers have developed other versions of the same drug and sold them under different brand names.
In short, the coverage of weight loss medications depends on both the insurer and their medical officers to approve the medication for insurance coverage, and that usually depends on whether you have a diagnosed obesity-related medical problem.
Weight Loss Injection Medication
Among the proliferation of new weight loss treatments in recent years, there has been a rise in weight loss injections that have become very popular choices for patients. This group of weight loss medications — which include both pills and injectable weight loss medication — are known as GLP-1 drugs, and they can be prescribed for for chronic weight management and to treat obesity in addition to diabetes. GLP-1 medications achieve this by imitating hormones in the body that control functions such as blood sugar levels, hunger, and digestion. This will help the patient achieve and maintain a healthier weight as well as lower cholesterol, blood pressure reducing the risk of heart disease, heart attacks, or strokes
Weight loss injectable medications, in particular, are liked because they can be applied once per week instead of being taken daily like pills, which makes them easier to manage. The injectable weight loss medications currently on the market are also markedly more effective than older generations of treatments, adding to the hype amongst patients.
While weight loss medications in the GLP-1 category have become quite popular with patients through both traditional media coverage and social media, the reality is that the FDA has only approved some versions of them, and they have to be paired with a proper diet and an exercise routine to safely lose weight while reducing the risks and complications of obesity.
Is Weight Loss Medication Covered By Insurance?
As we mentioned above in the article, it really depends on what type of insurance you have.
Medicare will not cover the price of weight loss injections if they’re being used specifically for weight loss. On the other hand, Medicare Part D can sometimes cover common weight loss medications like Wegovy (a popular weight loss injectable medication used to reduce the risk of cardiovascular disease) and Ozempic. However, they have to be prescribed to treat other medical conditions like diabetes.
Medicaid, on the other hand, leaves the decision to the states themselves. As of 2024, a fee-for-service Medicaid plan will only cover weight loss medications in 16 states. Despite that, most people with access to Medicaid have a managed care plan and not a fee-for-service plan, further reducing the coverage of weight loss medication.
Employer-provided insurance plans are more of a crapshoot since most employers can decide (and most usually do) to severely limit or outright exclude medications commonly used for weight loss from their insurance plans. If not banned, then some companies choose to put hard caps on how long they will cover weight loss injectables and pills.
Trying Cheaper Weight Loss Drugs As Part Of Your Plan
It’s not generalized, but some insurance companies will only approve some weight loss injectables (which tend to be more expensive) if you agree to try other, cheaper options for a set period of time first. Be sure to contact your insurance carrier and ask about this possibility, as well as the injectable weight loss drug you’re interested in, before asking your doctor to prescribe you an expensive weight loss medication.
How Much Do Injectable Weight Loss Drugs Cost Without Insurance?
On average, the price for the most popular and commonly prescribed weight loss medications ranges from around $900 to over $1,400 per month in the U.S. Wegovy, one of the most popular injectable weight loss drugs, is FDA-approved and has the same active ingredient as Ozempic, and has a monthly cost of $1,350. However, the retail price will vary by pharmacy.
Drug manufacturers can sometimes provide patients with discounts and coupons, but this still leaves consumers with bills of hundreds or thousands of dollars per month for their prescriptions. Again, Medicare will not legally cover any chronic weight loss medication, injectable or otherwise, for anything outside of its FDA approval label.
Appealing Your Health Insurance’s Denial Of Weight Loss Injectables
If you have been prescribed an injectable weight loss medication by your doctor, of which your insurer has denied coverage, you are within your legal right to appeal this decision. The grounds of the appeal should be that your insurance company is denying benefits for a service that your doctor and you believe to be medically necessary.
Boston Medical Group Can Help You on Your Weight Loss Journey
The coverage of injectable weight loss medications by insurance remains a complex and often frustrating issue for many seeking help with obesity. While certain medications may be covered under specific conditions, such as being prescribed for conditions other than weight loss, many patients may find themselves facing high out-of-pocket costs.
For those considering injectable weight loss medications, it is crucial to thoroughly discuss with healthcare providers not only the potential benefits and risks associated with these treatments but also the financial implications.
Remember, the journey to effective weight management is unique to each individual and may require a combination of approaches, including medication, diet modification, physical activity, and behavioral changes.
Consulting with specialized medical providers like the Boston Medical Group can provide tailored advice and support tailored to your specific health needs and financial situation.
