Orlando Harmon
Weight loss medications are attracting a lot of media attention, and with that, more patients are asking about their costs. The short answer is that weight loss drugs are usually not covered by insurance, and Medicare is barred by law from covering them. However, Medicaid covers some weight loss drugs in some states, and a small number of American insurance providers and plans cover weight loss drugs for obesity, but eligibility criteria must be met.
| Characteristics | Values |
|---|---|
| Insurance coverage for weight loss medication | Not usually covered by insurance unless treating type 2 diabetes or an obesity-related medical problem |
| Exceptions | Some state Medicaid programs cover weight loss drugs; Medicare is prohibited by law from covering weight loss medication |
| Recommendations for patients without insurance coverage | Consider generic versions of older drugs; use GoodRx or similar services to compare prices and find coupons; patient assistance programs may offer discounted pricing |
| GLP-1 medications | May be covered by insurance in the future as they can help with lowering risks |
| Injectable medications | May be covered by insurance if prescribed for type 2 diabetes, but usually not for obesity |
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What You'll Learn
Medicaid and weight loss medication
Medicaid coverage varies from state to state, and each state can decide whether to cover obesity drugs under Medicaid. While some states may cover weight loss medication, others may not. This is because weight-loss drugs are included in a small group of drugs that can be excluded from coverage under the Medicaid Drug Rebate Program (MDRP).
The MDRP requires Medicaid programs to cover nearly all of a participating manufacturer’s Food and Drug Administration (FDA)-approved drugs for medically accepted indications. However, drugs for anorexia, weight loss or weight gain, promoting fertility, cosmetic purposes, and symptomatic relief of coughs and colds can be excluded from coverage.
The FDA has approved three GLP-1s for the treatment of obesity: Saxenda (liraglutide), Wegovy (semaglutide), and Zepbound (tirzepatide). State Medicaid coverage of these is optional. However, as of July 1, 2024, 11 out of 12 states that reported coverage of GLP-1s also reported that utilization controls applied, with the most common being prior authorization and/or BMI requirements.
It is important to note that even with insurance, weight loss medications can still be costly. If your insurance does not cover weight loss medication, you may be able to consider generic versions of older drugs, such as bupropion, liraglutide, or orlistat. Additionally, you have the right to appeal your health plan's denial of benefits for covered services that you and your healthcare provider believe are medically necessary.
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Medicare and weight loss medication
Medicare does not typically cover weight loss medication. By law, Medicare is prohibited from covering weight loss drugs due to past safety concerns. In the 1990s, a combination of fenfluramine and phentermine, branded as fen-phen, was marketed as a "miracle" weight loss drug. However, it was later discovered that fen-phen caused heart valve damage, leading to its removal from shelves in 1997. As a result, the federal government barred Medicare from covering drugs where the risks outweighed the benefits, particularly cosmetic benefits.
Medicare Part D will cover certain medications, such as Ozempic, but only if they are prescribed for a purpose other than weight loss. For example, Ozempic is often prescribed to help manage type 2 diabetes, and in such cases, it may be covered by Medicare Part D. However, if Ozempic is prescribed solely for weight loss, it is not likely to be covered by Medicare, and patients will have to pay out of pocket. Similarly, Wegovy, an injectable semaglutide used for weight loss, is not covered by Medicare for obesity unless the patient also has an accompanying cardiovascular risk.
Medicare Advantage plans may include additional benefits that can help with weight loss, such as fitness programs. Additionally, patients on Medicare with limited resources may be able to get assistance through the Medicare Part D Extra Help program. Many drug manufacturers also offer patient assistance programs with discounted pricing.
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Private insurance and weight loss medication
Private insurance coverage for weight loss medication is a complex issue and varies depending on the insurer and the specific medication in question. While some private insurance plans may provide coverage for weight loss medications, others may exclude them from their list of covered benefits. Ultimately, it is up to each insurer to decide whether to cover weight loss medications and under what circumstances.
Some private insurance plans may require prior authorization or approval from their chief medical officer before covering weight loss medications. Additionally, certain employers who offer health coverage may choose to exclude specific weight loss drugs, such as GLP-1 drugs, from their sponsored health plans. Therefore, it is essential to carefully review the details of your specific insurance plan to understand its coverage policies regarding weight loss medications.
Insurers and employers who sponsor health coverage often consider weight loss a cosmetic need rather than a medical one. As a result, they may be reluctant to cover weight loss medications. However, if a person has an obesity-related medical problem, such as high cholesterol or high blood pressure, their insurer may be more likely to cover weight loss medications as a medically necessary treatment.
It is worth noting that some weight loss medications, particularly newer drugs, can be very expensive. For example, as of October 2022, a month's supply of Wegovy (semaglutide) cost $1,300. Therefore, even with insurance coverage, out-of-pocket expenses for these medications can still be significant.
If your insurance plan denies coverage for a prescribed weight loss medication, you have the right to appeal their decision. There are typically two types of appeals: internal appeals and external reviews. By filing an appeal, you can present your case and provide supporting documentation from your healthcare provider to demonstrate the medical necessity of the medication.
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Appealing a health insurer's denial of weight loss medication
Weight loss medications can be expensive, and insurance coverage for them varies. Medicare, for example, is barred from covering weight loss medication by law due to past safety concerns. Commercial insurers also tend not to cover weight loss medications, often considering weight loss a cosmetic need rather than a medical one. However, if your insurance company does cover weight loss medications, they may still deny a request for a specific drug. If your health insurer has denied coverage for weight loss medication, you have the right to appeal their decision.
Internal Appeal and External Review
There are two kinds of appeals: internal appeal and external review. An internal appeal can be filed by you or your healthcare provider. If you choose to write the appeal letter yourself, it must be tailored to the specific reason the insurance company denied your request. For example, if the reason for the denial is "not medically necessary", review your member handbook to understand the health plan's definition of medical necessity and provide the necessary information accordingly. Your insurance company is legally required to provide your healthcare provider with a detailed explanation of the denial, and they should also have the opportunity to speak directly with the claim reviewer.
Provide Additional Information
To successfully appeal a claim, you must provide additional information that supports the medical necessity of the weight loss medication being requested. Make sure all factors of your severe obesity status have been reported, such as co-morbid conditions that affect you (heart disease, diabetes, sleep apnea, etc.). If you have tried other methods or treatments, include information about this in your appeal letter.
Contact Your Insurer
By speaking directly with your insurance company, you can verify the reason for the denial and make sure that a simple error wasn't the cause. This will also provide you with additional information about how to tailor your appeal to maximize your chances of approval.
Consider Other Options
If your insurance won't cover weight loss medications, you may want to consider generic versions of older drugs, such as bupropion, liraglutide, or orlistat. Patients on Medicare with limited resources may be able to get help through the Medicare Part D Extra Help program. Many drug makers also offer patient assistance programs that include discounted pricing.
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Generic weight loss drugs
Weight loss drugs are medications that promote weight loss and are usually used in conjunction with a reduced-calorie diet and exercise. Some weight loss drugs are injectables, which are typically used to treat type 2 diabetes but may also be prescribed off-label for weight loss.
Generic drugs are typically older drugs that have been on the market for a while and are more affordable than newer drugs. Here are some generic weight loss drugs:
- Bupropion: Bupropion is an antidepressant that can be used to promote and maintain weight loss, especially in adults with weight-related medical problems. It is often combined with naltrexone (brand name Contrave).
- Liraglutide (Saxenda): Liraglutide is a GLP-1 agonist that promotes weight loss by decreasing appetite. It is often used in conjunction with diet and exercise.
- Orlistat (Xenical, alli): Orlistat promotes weight loss by reducing the amount of fat absorbed by the body from food. It is often combined with diet and exercise.
- Phentermine (Adipex-P, Lomaira): Phentermine promotes weight loss by decreasing appetite and is often used for a short period. It is combined with a reduced-calorie diet and exercise.
- Phendimetrazine (Bontril, Melfiat): Phendimetrazine is used to promote weight loss when other therapies have not worked or are not tolerated. It is typically used for a short period and in combination with diet and exercise.
Insurance Coverage for Weight Loss Medication
Insurance coverage for weight loss medication varies and is often not covered. Medicare, for example, is prohibited by law from covering weight loss medication due to past safety concerns. Commercial insurers and employers who sponsor health coverage often consider weight loss a cosmetic need rather than a medical one. However, some insurance plans may cover weight loss medication if it is deemed medically necessary, especially if it is used to treat obesity-related medical problems such as high cholesterol or high blood pressure. Patients whose insurance does not cover weight loss medication may consider generic versions of older drugs, which tend to be more affordable, or look for pharmacy coupons and patient assistance programs to help offset the cost.
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Frequently asked questions
It depends on the state. Medicaid covers some weight-loss drugs in some states. For example, Wegovy is covered by insurance in some states. However, most states do not use their authority to expand public and private insurance coverage of obesity assessment and treatment.
Weight loss drugs are one of the classes of drugs that Medicaid programs can exclude from coverage by federal law. Many insurers and employers who sponsor health coverage consider weight loss a cosmetic need rather than a medical one. Medicare is barred from covering weight loss medication by law due to past safety concerns.
You can consider generic versions of older drugs, such as bupropion, liraglutide, or orlistat. Patients on Medicare with limited resources may be able to get help through the Medicare Part D Extra Help program. Many drug makers offer patient assistance programs that include discounted pricing. You can also use a health savings account (HSA) or flexible spending account (FSA) to reduce the cost.
A small number of American insurance providers and plans cover weight loss drugs for obesity, but eligibility criteria must be met. Weight loss medications that are FDA-approved to treat type 2 diabetes, such as Mounjaro (tirzepatide) and Ozempic (semaglutide), are often covered by insurance.
