Jeffrey Wade
Cigna insurance plans generally do not cover weight-loss medications, which often carry side effects such as nausea, vomiting, headaches, and changes in bowel habits. However, a select few medications, such as Contrave, Adipex-P, and Qsymia, are covered when they meet certain criteria for medically necessary drugs. Cigna also covers Ozempic, but only when prescribed for Type 2 diabetes, as it is not approved for weight loss. Many Cigna plans will cover Wegovy for chronic weight management, but only with prior authorization and proof of medical necessity. Cigna has recently announced that it will cap how much insurance can spend on weight-loss drugs in an effort to expand coverage.
| Characteristics | Values |
|---|---|
| Insurance coverage for weight-loss medication | Cigna insurance plans generally do not cover weight-loss medicines, but a few medications (e.g., Contrave, Adipex-P, and Qsymia) are covered when they meet specific criteria for medically necessary drugs. |
| Weight-loss medication covered by Cigna | Cigna covers Ozempic when prescribed for Type 2 diabetes but not for weight loss. Many Cigna plans cover Wegovy for chronic weight management with prior authorization and proof of medical necessity. |
| Side effects of weight-loss medication | Nausea, vomiting, headaches, and changes in bowel habits. Some medicines may also cause changes in blood pressure and bowel habits. |
| Effectiveness of weight-loss medication | Results vary for each person, with some people losing 5% to 16% or more of their body weight. Weight-loss medicines are used long-term alongside healthy eating and increased physical activity. |
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What You'll Learn
- Cigna insurance plans don't usually cover weight-loss medication
- Cigna may cover weight-loss medication in specific circumstances
- Cigna covers Ozempic, but only for Type 2 diabetes
- Cigna covers Wegovy for chronic weight management with prior authorisation
- Cigna's Evernorth will limit spending increases for GLP-1s to 15% annually
Cigna insurance plans don't usually cover weight-loss medication
Cigna insurance plans typically do not cover weight-loss medication. However, there are some exceptions and special circumstances where coverage may be provided. For instance, Cigna may cover weight-loss medications like Contrave, Adipex-P, and Qsymia when they meet certain criteria for medically necessary drugs. Additionally, Cigna's national plan includes Zepbound, Wegovy, Mounjaro, and Ozempic in its formulary, the list of medications it will cover in specific circumstances. These drugs are usually classified as tier-4 (non-preferred) drugs, requiring prior authorization and not typically covered under standard plans.
Prior authorization and proof of medical necessity are generally required for Cigna to cover weight-loss medications. To demonstrate medical necessity for Wegovy, individuals must have a body mass index (BMI) of 30 or higher or a BMI of 27 or higher with a weight-related comorbidity approved by Cigna, such as hypertension, Type 2 diabetes, obstructive sleep apnea, or CV disease. Similarly, Cigna may cover Mounjaro when prescribed for Type 2 diabetes but not for weight loss, Type 1 diabetes, diabetes prevention, or metabolic syndrome.
Cigna's approach to covering weight-loss medications is influenced by the high costs associated with these treatments. In 2024, the company announced plans to cap how much insurance can spend on weight-loss drugs, aiming to expand coverage by limiting spending increases to a maximum of 15% annually. This strategy provides "financial predictability" for health plans and employers, helping to ensure broader access for eligible patients.
While Cigna does not typically cover weight-loss medications, it is important to note that coverage can vary depending on the specific plan and the circumstances. It is always advisable to review your plan documents or consult a Cigna Healthcare representative to understand the details of your coverage.
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Cigna may cover weight-loss medication in specific circumstances
Cigna insurance plans generally do not cover weight-loss medications as a broad category. However, certain medications, such as Contrave, Adipex-P, and Qsymia, are covered when they meet specific criteria for medically necessary drugs. The coverage depends on the specific plan and whether it is a self-insured or fully insured product. For instance, Cigna covers Ozempic when prescribed for Type 2 diabetes but not for weight loss. Similarly, Mounjaro is covered by Cigna when prescribed for Type 2 diabetes, but not for weight loss.
Cigna's coverage of GLP-1 agonists, including Zepbound, Wegovy, Mounjaro, and Ozempic, is more complex. While these drugs are listed as "excluded" or "not covered," they are still included in Cigna's formulary, the list of medications covered in specific circumstances. These drugs typically require prior authorization and are classified as tier-4 (non-preferred) drugs, indicating that they are not usually covered under standard plans.
Cigna has recently made efforts to expand insurance coverage for weight-loss drugs by capping how much health plans and employers spend on them annually. This initiative aims to address the high costs of weight-loss treatments and ensure broader access for eligible patients. As a result, Cigna's pharmacy benefits management unit will limit spending increases for these treatments to a maximum of 15% per year.
It is important to note that weight-loss medications may be an option for individuals with obesity or weight-related health issues, such as high blood pressure or diabetes. These medications can assist those who have been unable to lose weight through diet and exercise alone. However, it is crucial to consult with a doctor to understand the potential side effects and determine the most suitable treatment option.
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Cigna covers Ozempic, but only for Type 2 diabetes
Cigna insurance plans generally do not cover weight-loss medications. However, a few select medications, such as Contrave, Adipex-P, and Qsymia, are covered when they meet specific criteria for medically necessary drugs.
Among the GLP-1 agonist medications, Cigna's national plan lists Zepbound and Wegovy as "excluded drugs" and Mounjaro and Ozempic as "not covered". Despite this designation, these drugs are still included in Cigna's formulary, the list of medications it will cover in certain circumstances. Ozempic, for instance, is covered by Cigna but only when prescribed for Type 2 diabetes. It is not approved for weight loss, treating Type 1 diabetes, diabetes prevention, or metabolic syndrome alone. Prior authorization may also be required, depending on the individual's medical history.
Ozempic (semaglutide) is a medication that may aid in weight loss by helping to reduce food intake. It is typically administered as a shot or pill. While it has been shown to be effective for weight loss, it is primarily approved by the Food and Drug Administration (FDA) for the treatment of Type 2 diabetes.
It is important to note that receiving coverage for Ozempic or any other medication is contingent upon the specific Cigna plan held by the individual. There may be differences between Cigna's self-insured plans, where employers assume all risk, and fully insured products, where Cigna bears the risk. Cigna provides employers with flexibility in choosing to cover GLP-1s for their employees and offers cost-protection measures. Ultimately, the coverage of these drugs is dependent on the individual's plan.
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Cigna covers Wegovy for chronic weight management with prior authorisation
Cigna insurance plans generally do not cover weight-loss medications, but there are exceptions. For instance, Cigna covers Wegovy for chronic weight management with prior authorisation and proof of medical necessity. Wegovy is a weight-loss medication that may help you eat less and is administered as a shot or pill.
To demonstrate medical necessity for Wegovy, you must have performed behavioural modifications and dietary restrictions for at least three months and meet at least one of the following criteria:
- A body mass index (BMI) of 30 or higher.
- A BMI of 27 or higher, plus a weight-related comorbidity approved by Cigna, such as hypertension, Type 2 diabetes, obstructive sleep apnea, or CV disease.
It is important to note that weight-loss medications may have side effects such as nausea, vomiting, headaches, and changes in bowel habits. These medications are typically used long-term alongside healthy eating and increased physical activity.
Cigna has recently announced that it will cap how much insurance can spend on weight-loss drugs, including GLP-1s, to expand coverage for these treatments. This decision comes as many insurers are reconsidering whether to cover weight-loss treatments due to their high costs.
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Cigna's Evernorth will limit spending increases for GLP-1s to 15% annually
Cigna's subsidiary, Evernorth Health Services, has announced that it will limit spending increases for GLP-1 weight loss medications to a maximum of 15% annually. This decision is aimed at helping companies and health plans manage their spending on these drugs, which can be costly.
GLP-1 medications, which include drugs like Wegovy, Ozempic, Mounjaro, and Zepbound, are used for weight management and the treatment of Type 2 diabetes. While Cigna's national plan lists Zepbound and Wegovy as "excluded drugs" and Mounjaro and Ozempic as "not covered", the company has stated that these drugs are still included in its formulary. This means they can be covered in certain circumstances with prior authorization and medical necessity.
The spending cap by Evernorth is designed to provide greater predictability and control over the cost of GLP-1 therapies. This move comes as many insurers are considering whether to cover these treatments or remove them from their plans due to their high costs. GLP-1 drugs can cost around $1,000 per patient per month, and some health plans are experiencing annual cost increases of 40%-50% for these medications.
By capping spending increases at 15%, Evernorth aims to strike a balance between providing access to these treatments and managing the financial burden on employers and health plans. This decision aligns with Cigna's goal of expanding insurance coverage for weight loss and diabetes drugs while also controlling costs.
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Frequently asked questions
Cigna insurance plans generally do not cover weight-loss medicines as a broad category. However, a select few medications, such as Contrave, Adipex-P, and Qsymia, are covered when they meet certain criteria for medically necessary drugs.
Cigna may cover medications such as Contrave, Adipex-P, and Qsymia when they are deemed medically necessary.
Many Cigna plans will cover Wegovy when prescribed for chronic weight management, but prior authorization and proof of medical necessity are required. To demonstrate medical necessity, individuals must have performed behavioural modifications and dietary restrictions for at least three months and meet specific BMI and weight-related comorbidity criteria.
Cigna covers Ozempic when it is prescribed for Type 2 diabetes, but not for weight loss treatment.
Common side effects of weight-loss medications include nausea, vomiting, headaches, and changes in bowel habits. Some medications may also cause blood pressure changes and other issues. It is important to consult with a doctor about any side effects and to understand the potential risks and benefits of these medications.
