Jeffrey Wade
Quartz Insurance offers a range of health plans, and the coverage of weight loss medication depends on the specific plan and state regulations. Generally, Quartz Health Solutions covers weight loss medication when it is considered medically necessary for obesity management in adults with a BMI of 30 or greater, or 27 with a weight-related condition. The Virta program, offered by Quartz, is a weight loss and type 2 diabetes reversal program that is covered for those with a BMI of 30 or greater. It is important to note that certain drugs may not be covered by specific plans, and it is recommended to contact Quartz Health Solutions directly for accurate and up-to-date coverage information.
| Characteristics | Values |
|---|---|
| Company Name | Quartz |
| Drug Covered | Semaglutide (Wegovy) |
| Coverage | Depends on the specific plan and state regulations |
| Requirements | Body Mass Index (BMI) of 30 kg/m2 or greater, or 27 kg/m2 with at least one weight-related condition such as type 2 diabetes, hypertension, or dyslipidemia |
| Age Requirement | 18 years or older |
| Diagnosis Requirement | Obesity, defined as a BMI of 30 kg/m² or greater |
| Medical History | Documented history of failure to lose weight or maintain weight loss with lifestyle interventions such as diet and exercise |
| Provider | Must be a credentialed provider within the Quartz Health Solutions network |
| Denial Reasons | Inadequate documentation supporting the necessity of the treatment for obesity management, concurrent claims for similar weight loss drug therapies, cosmetic weight loss or weight management purposes rather than clinically substantial obesity treatment, requests from individuals under the FDA-approved age |
| Cost without Insurance | $1,200 to $1,400 for a one-month supply |
| Alternative Option | Virta (for members with Type 2 diabetes or a BMI of 30 or greater) |
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What You'll Learn
Virta's weight loss program for Quartz members
Virtua Health offers a weight loss program for Quartz members with a BMI of 30 or greater. The program is also available to those with Type 2 diabetes. It is covered by Quartz Health Solutions and is available at no extra cost to eligible members.
The program is designed to help members lose weight and sustain it over time by changing what they eat. It is not a calorie-restrictive diet but rather focuses on nutrition and helping members gain control of their cravings. The program also helps members lower their blood sugar and reduce medications. It is backed by clinical research and supported by a team of medical providers and health coaches.
To be eligible for the program, members must be 18 years or older and enrolled in an eligible health plan through Quartz. Eligible plans include most commercial fully-insured, State of Wisconsin Health Insurance Group, Medicaid, Quartz Medicare Advantage (HMO), and Dual Eligible plans.
It is important to note that the coverage for weight loss medication under Quartz Health Solutions may vary depending on the specific plan and state regulations. For instance, Quartz covers Semaglutide (Wegovy) when it is considered medically necessary for obesity management in adults with a BMI of 30 or greater, or 27 with at least one weight-related condition. Prior authorization and documentation of previous failed weight loss attempts may also be required.
For specific questions about coverage, it is recommended to contact Quartz Health Solutions directly or consult with a healthcare provider to ensure all medical criteria and documentation are in order.
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Semaglutide (Wegovy) medication coverage
Semaglutide (Wegovy) Medication Overview:
Semaglutide (Wegovy) is a prescription medication given via injection. It is used in conjunction with a reduced-calorie diet and increased physical activity to help reduce the risk of major cardiovascular events such as heart attacks or strokes in adults with obesity or overweight and known heart disease. It may also aid in weight loss and weight management for adults and children aged 12 years and older with obesity or overweight-related medical issues. However, it is not recommended for those under 12 years of age due to unknown safety and effectiveness.
Quartz Insurance Coverage:
Quartz Insurance provides various health plans, including employer-sponsored plans, individual/family plans, and Medicare Advantage plans. While Quartz is committed to providing superior customer service and pharmacy benefits, it is not clear whether Semaglutide (Wegovy) is specifically covered. The coverage depends on the specific plan and the state in which the member resides or their employer is based.
To verify if Semaglutide (Wegovy) is covered under their plan, Quartz members can refer to their Quartz Prescription Drug Benefit Rider or contact Quartz Customer Success at (800) 362-3310. They can also access their pharmacy benefits through the Quartz MyChart tool or by entering their member or group number on the Formulary Lookup.
Additional Coverage Options:
For those seeking coverage for Semaglutide (Wegovy), there are a few options provided by the medication's manufacturer:
- Wegovy® (semaglutide) injection 2.4 mg: The manufacturer offers a coverage check on their website and provides information on potential costs and savings.
- NovoCare®: This program is mentioned on the Wegovy website as a way to check coverage for the medication.
It is important to note that insurance coverage for weight loss medications like Semaglutide (Wegovy) may vary based on individual plans and their specific exclusions and inclusions. Contacting the insurance provider directly or referring to the plan's formulary (list of covered medications) is the best way to confirm coverage.
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Requirements for weight loss medication coverage
While Quartz does not explicitly mention weight loss medication coverage, it does provide health plans and programs that can help with weight loss. For instance, the Type 2 diabetes reversal program provided by Virta is available for free to Quartz health plan members with Type 2 diabetes. Virta's weight loss program is also covered for those with a BMI of 30 or greater. This program helps members lose weight and sustain it over time by helping them change what they eat.
Regarding weight loss medication coverage, in general, it is important to note that many insurers do not cover these medications as they consider weight loss a cosmetic need rather than a medical one. However, some insurance plans may cover weight loss medications under certain conditions. Here are some general requirements that may apply:
- Plan Type and Specifics: Coverage for weight loss medication can depend on the specific details of your insurance plan. Some plans may have exclusions or additional requirements for this type of treatment. For example, Quartz mentions that certain drugs on their formulary (list of covered medications) may not be covered by all benefit plans, and it is important to verify your specific plan's coverage.
- Medical Necessity: To be eligible for coverage, weight loss medication is typically prescribed for individuals with obesity or those with a high BMI (Body Mass Index). For instance, the medication Wegovy is approved for individuals with a BMI of 30 or greater or a BMI of 27 or greater with comorbidities like high blood pressure or diabetes. A medical professional will assess your health condition and determine if weight loss medication is medically necessary for you.
- FDA Approval and Generic Options: Insurance companies are more likely to cover weight loss medications that are approved by the FDA. Additionally, older weight loss medications with available generics are more likely to be covered as they are more affordable than newer drugs. Brand versions are often removed from insurance formularies when FDA-approved generics become available.
- Clinical Research and Evidence: Insurance providers may require evidence-based treatment for obesity. This includes clinical research and data supporting the safety and effectiveness of the medication. For example, data showing that a medication offers cardiovascular benefits or helps prevent diabetes and heart disease can strengthen the argument for coverage.
- Geographic Location: The state you live in can impact your coverage. Different states may have varying requirements and regulations regarding weight loss medication coverage. Quartz, for instance, mentions that its formulary applies to specific states: Wisconsin, Minnesota, and Iowa.
- Employer-Based Coverage: If you have employer-based insurance, the coverage for weight loss medication can depend on the specific health plan offered by your employer. Additionally, the number of employees in the company may be a factor, as smaller businesses may have different plan options than larger ones.
It is important to note that insurance coverage for weight loss medication is a complex and evolving topic. The best way to determine if your specific plan covers weight loss medication is to contact Quartz customer support or member services and provide your member or group number. They can help you understand your plan's formulary and any specific requirements or exclusions related to weight loss medication coverage.
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Denial reasons for weight loss medication
Weight loss medications are often not covered by insurance due to their high costs. Payers tend not to cover weight loss medications, and this includes commercial insurers as well as Medicare and Medicaid. Medicare is legally prohibited from covering weight loss medications due to past safety concerns. The federal government disallowed Medicare from covering drugs viewed as having risks that outweigh the benefits, namely cosmetic benefits. This dates back to the fallout from fen-phen in the 1990s, which was a "miracle" drug for rapid weight loss but was later found to cause heart valve damage.
Insurers may also deny coverage for weight loss medications because the long-term effects of these drugs are not yet fully known. This uncertainty about the potential side effects of these medications may lead insurers to err on the side of caution and deny coverage.
Additionally, there is a misalignment of incentives. For example, an insurer covering a 45-year-old may pay for weight loss medications for a decade, but once that person retires, their healthcare costs shift to Medicare, which would then reap the benefits of preventing their obesity.
It is important to note that some insurance plans may cover weight loss medications in certain circumstances. For instance, Quartz members with a BMI of 30 or greater have access to Virta's weight loss program, which helps individuals lose weight by changing what they eat. This program is offered at no extra cost to eligible Quartz health plan members. However, it is not a medication-based program, and there may be specific criteria that members must meet to qualify.
If you are seeking coverage for weight loss medication, it is essential to carefully review your insurance plan's benefits and exclusions. Contacting your insurance provider directly to discuss your specific plan and coverage options is always recommended.
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Non-pharmacy weight loss programs covered by Quartz
While I could not find exhaustive information on non-pharmacy weight loss programs covered by Quartz, I did find that Virta Health offers a weight loss program covered by Quartz.
Virta Health is a virtual clinic that helps people with a BMI of 30 or greater lose weight and prevent rising blood sugar. The program is based on nutrition science and does not involve calorie restriction. Instead, it focuses on helping people eat foods that are right for them and curbing cravings. The program also provides access to a health coach and free testing supplies.
Virta's weight loss program is available at no extra cost to Quartz health plan members with Type 2 diabetes. The program is valued at more than $3,000 and includes tools and recipes that fit your tastes, as well as chat support from a coach for motivation, accountability, and answers to your questions.
The Virta Health program is currently a pilot program for State of Wisconsin Group Health Insurance Program members, available to 2025 members on a trial basis. It is offered by Quartz Health Benefit Plans Corporation, Quartz Health Plan Corporation, Quartz Health Plan MN Corporation, and Quartz Health Insurance Corporation, which are separate legal entities.
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Frequently asked questions
Quartz Insurance may cover weight loss medication, but it depends on the specific plan and state regulations. Generally, Quartz covers weight loss medication when it is considered medically necessary for obesity management in adults.
To determine if your weight loss medication is covered, you should first consult your plan details and check the formulary, which is the list of medications covered by Quartz. You can access this information through Quartz MyChart or by entering your member number on the Formulary Lookup. If you are unsure, it is recommended to contact Quartz Health Solutions directly or consult with Member Services.
Yes, there are specific requirements for weight loss medication to be considered for coverage by Quartz Insurance. Generally, a patient must meet the diagnostic requirement of obesity, which is defined as a Body Mass Index (BMI) of 30 or greater. Alternatively, the patient may have a BMI of 27 or higher with at least one weight-related condition, such as type 2 diabetes. Additionally, patients must be adults aged 18 or older, and they should have a documented history of unsuccessful weight loss attempts through lifestyle interventions like diet and exercise.
Yes, Quartz Insurance covers the Virta weight loss program for members with a BMI of 30 or greater. This program focuses on nutrition science and provides support from health coaches to help individuals lose weight and sustain it over time.
There are several reasons why weight loss medication may be denied coverage by Quartz Insurance. This includes prescriptions originating from non-credentialed providers or outside of the Quartz Health Solutions network, lack of documentation supporting the necessity of the treatment for obesity management, concurrent claims for similar weight loss drug therapies, and requests for cosmetic weight loss rather than clinically substantial obesity treatment.
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