Estimated reading time: 6 minutes
Weight-loss drugs, particularly GLP-1 medications, have gotten a lot of attention lately for their results in helping people shed pounds. However, their high cost and lack of coverage has left many people out in the cold! Without insurance paying some of the tab, it can be a strain to afford these medicines. In fact, their high cost is often cited as one of the main reasons people avoid taking GLP-1s. PatientsLikeMe has thousands of members living with either type 2 diabetes or obesity. Some of these members are on GLP-1 medications to help control blood sugar levels and lose weight.
While it is not as simple as saying one issue is the reason people stop taking a certain medication, cost is a driving factor. So what do you need to know about insurance coverage for weight-loss medications? We’ll cover the types of drugs, when insurance is likely to cover them, and how to find out if you qualify for coverage.
What Are Weight-Loss Medications?
Many people are familiar with diabetes medications like Ozempic or Mounjaro, but did you know that some versions of these drugs are also used for weight loss? These medications belong to a group called GLP-1 receptor agonists, and they work by both lowering blood sugar levels and helping control appetite. The FDA has approved1 some of these drugs specifically for weight loss:
- Wegovy (semaglutide)
- Saxenda (liraglutide)
- Zepbound (tirzepatide)
These medications are often prescribed along with a diet and exercise plan to help manage weight and prevent obesity-related health issues.
Will My Insurance Cover Weight-Loss Medications?
Insurance coverage for weight-loss medications depends on a few factors, including the specific drug, your health condition, and your insurance provider.
Off-Label Uses
Some medications, such as Ozempic and Mounjaro, are approved by the FDA to treat type 2 diabetes. While they can be effective for weight loss, most insurance companies won’t cover them unless you have diabetes. Even if a doctor prescribes these drugs for weight loss (a practice known as “off-label2” use), insurance companies are not required to cover them.
FDA-Approved Weight-Loss Medications
Drugs like Wegovy, Saxenda, and Zepbound are specifically approved for weight management. However, getting insurance to cover these medications isn’t always easy. Many insurance companies will only approve them if you have a health condition related to obesity3, such as:
- High cholesterol
- High blood pressure
- Type 2 diabetes
Just having a high body mass index (BMI) might not be enough for coverage. Your doctor may need to prove that the medication is medically necessary to treat an obesity-related health issue before your insurance will pay for it.
Employer-Sponsored Health Plans
Some employers choose not to include weight-loss medications in their health insurance plans. This means that even if a drug is FDA-approved for weight loss, your plan may exclude it. Some plans also require prior authorization. This is a process where your doctor must get approval from the insurance company before the medication can be covered. Get in touch with your insurance provider to find out if your plan covers weight-loss medications.
The Cost of Weight-Loss Medications
Weight-loss medications, especially newer ones like Wegovy and Zepbound, can be very expensive. Without insurance, the cost can reach $1,300 or more4 for a month’s supply. Even with insurance, you could still be responsible for a portion of the cost, which could be several hundred dollars per month. Some drug manufacturers offer discount programs, but these programs are not available to everyone and may not make a significant difference in overall cost.
Why Medicare Doesn’t Cover Weight-Loss Medications
Unfortunately, Medicare, the government insurance program for people over 65 and certain younger people with disabilities, does not cover weight-loss medications. This is due to a law passed in the early 2000s, after previous weight-loss drugs were found to have dangerous side effects. Although newer drugs like GLP-1 receptor agonists have been shown to be safe and effective, Medicare still cannot cover them by law. If your insurance company denies coverage for a weight-loss medication, don’t give up! You have the right to appeal the decision5. There are two types of appeals:
- Internal Appeal: You or your doctor can ask the insurance company to review and reconsider their decision.
- External Review: If your internal appeal is denied, you can request an independent review from a third-party organization.
It’s important to have your doctor provide detailed information about why the medication is medically necessary for your health, which can improve your chances of approval.
Why Weight-Loss Medications Matter
The American Medical Association (AMA) has officially recognized obesity as a disease, and they believe that weight-loss medications should be considered medical treatments. Studies show that obesity can lead to serious health conditions like heart disease, diabetes, and stroke. By treating obesity early, we can prevent these conditions and improve overall health.
The Future of Coverage
There is growing pressure on insurance companies to cover weight-loss medications, as obesity becomes more recognized as a serious health issue. Organizations like the AMA are asking insurers to treat obesity as a disease and to cover evidence-based treatments, including medications. In some states, new laws are being considered to require insurance companies to cover weight-loss drugs. However, changes like this take time, so it’s important to stay informed and ask your insurance provider about your options.
Weight-loss medications can be an important part of managing obesity, but they can also be expensive. Whether your insurance will cover these drugs depends on a few factors. These are things like your health condition, your insurance plan, and the specific medication. If you’re thinking about taking a weight-loss medication, make sure to talk to your doctor and your insurance provider to understand your coverage and costs.
Taking control of your health has never been easier with PatientsLikeMe. Our platform empowers you to manage your wellness journey proactively. By joining a community who share your experiences and insights, you gain access to invaluable support and information tailored to your unique health needs. PatientsLikeMe offers tools to track your symptoms, treatments, and outcomes, enabling you to make informed decisions and communicate better with your healthcare providers. Additionally, evaluate the effectiveness of various treatments through shared patient data, ensuring you choose the best options for your health.
- https://www.niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity
- https://www.fda.gov/patients/learn-about-expanded-access-and-other-treatment-options/understanding-unapproved-use-approved-drugs-label
- https://www.niddk.nih.gov/health-information/weight-management/adult-overweight-obesity/health-risks
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8603328/
- https://www.healthcare.gov/appeal-insurance-company-decision/