Jeffrey Wade
Weight loss medication can be expensive, with a month's supply of some drugs costing over $1,000. Many patients are, therefore, reliant on insurance coverage to help them afford these medications. However, insurance coverage for weight loss medication is not guaranteed. Medicare, for example, is barred by law from covering weight loss medication due to past safety concerns. Commercial insurers and employer-sponsored health coverage may also not cover weight loss medication, as they often consider weight loss a cosmetic need rather than a medical one. This guide will explore the circumstances in which insurance covers weight loss medication and the options available to patients whose insurance does not cover it.
| Characteristics | Values |
|---|---|
| Cost of weight-loss medication | A month's supply can cost $1,300 |
| Insurance coverage | Payers tend not to cover weight-loss medication. This includes commercial insurers, Medicare, and Medicaid. |
| Reasons for lack of coverage | Weight loss is considered a cosmetic need rather than a medical one. |
| Exceptions | Insurance may cover weight-loss medication if it is deemed medically necessary due to an obesity-related medical problem, such as high cholesterol or high blood pressure. |
| FDA-approved weight-loss medications | Wegovy (semaglutide), Saxenda (liraglutide), Zepbound (tirzepatide) |
| Side effects | Nausea, vomiting, diarrhea, dizziness, mild tachycardia, headaches, low blood sugar, kidney problems, possible thyroid tumors, and cancer |
| Requirements for insurance coverage | Prior authorization from a healthcare provider may be required. |
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What You'll Learn
- Medicare and Medicaid do not cover weight loss medication
- Commercial insurers may also not cover weight loss medication
- Weight loss injectables are often not covered by insurance
- Prior authorization may be required for some prescription insurance plans
- Some employers exclude GLP-1 drugs from health plans
Medicare and Medicaid do not cover weight loss medication
Medicare and Medicaid do not cover weight-loss medication. By law, Medicare is prohibited from covering weight-loss medication due to 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 and was subsequently removed from the market in 1997. As a result, the federal government prohibited Medicare from covering drugs where the risks outweighed the benefits, particularly cosmetic benefits.
Despite this, there have been recent developments that may lead to a change in policy. In November 2024, the Biden administration proposed a new rule that would allow Medicare and Medicaid to cover weight-loss medication specifically for the treatment of obesity. This proposal recognises obesity as a chronic, widespread, and dangerous disease in the United States. The decision on whether to implement this proposal will fall to the incoming Trump administration.
While Medicare does not cover weight-loss medication, it does provide some services that can help individuals manage their weight. Medicare Part B covers obesity behavioural therapy in certain cases. This therapy includes an initial BMI screening, dietary assessment, and counselling to promote weight loss through diet and exercise. Additionally, Medicare Advantage plans may include fitness programs that can aid in weight management.
Medicare Part D, which was launched in 2003 as part of the Medicare Modernization Act, helps manage prescription drug costs. However, it does not address weight-loss medications specifically for obesity treatment. Nevertheless, if a weight-loss medication is also approved by the FDA for additional health benefits, such as treating Type 2 diabetes or cardiovascular disease, it may be covered under Medicare Part D. It is important to check the plan's formulary to determine which prescriptions are covered.
Medicaid, like Medicare, does not currently cover weight-loss medication. However, this may change if the Biden administration's proposal is accepted by the Trump administration. This expansion of coverage would significantly increase access to weight-loss medications for individuals with obesity.
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Commercial insurers may also not cover weight loss medication
Commercial insurers may not cover weight loss medication. This is because weight loss is often considered a cosmetic need rather than a medical one. Many insurers and employers who sponsor health coverage hold this view.
In the United States, Medicare is prohibited by law from covering weight loss medication due to past safety concerns. In the 1990s, a combination of fenfluramine and phentermine, branded as fen-phen, was marketed as a "miracle" drug for rapid weight loss. However, it was later discovered that fen-phen caused heart valve damage and was subsequently removed from shelves in 1997. As a result, the federal government prohibited Medicare from covering drugs where the risks outweighed the benefits, particularly cosmetic benefits.
While the Affordable Care Act of 2010 expanded coverage by commercial insurers to include the costs of interventions like bariatric surgery to treat obesity, it did not address weight loss medications. This means that commercial insurers are not required to cover weight loss medication and may choose not to do so.
Additionally, some employers choose to exclude weight loss medications, specifically GLP-1 drugs, from employer-sponsored health plans. Some insurance plans may also require prior authorization before approving coverage for certain medications. It is up to each insurer and its chief medical officer to decide whether to cover weight loss medications, and they may require individuals to have an obesity-related medical problem, such as high cholesterol or high blood pressure, to qualify for coverage.
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Weight loss injectables are often not covered by insurance
Some insurance plans require prior authorization before approval for weight loss injectables. It is up to each insurer and its chief medical officer to decide if these medications will be covered. Some employers choose to exclude GLP-1 drugs from employer-sponsored health plans.
If your doctor has prescribed weight loss injectables but your insurer denied coverage, 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. There are two types of appeals: internal appeal and external review.
Some drug manufacturers offer discount programs to help with the cost of weight loss injectables. However, consumers are often left paying hundreds of dollars out of pocket for their prescriptions.
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Prior authorization may be required for some prescription insurance plans
Prior authorization is a common requirement for prescription medication coverage, including weight loss treatments. This means that before insurance coverage is provided for a specific medication, the patient must first obtain approval from their insurance carrier.
Prior authorization for weight loss medication may be required for some prescription insurance plans, and it is up to each insurer to decide whether to include this coverage. Patients should check their specific plan details, as some plans may cover certain weight loss medications with prior authorization, while others may not cover them at all.
Insurers may require prior authorization for weight loss medication to assess the medical necessity of the treatment. Weight loss medications are often considered cosmetic rather than medically necessary by insurers and employers who sponsor health coverage. Therefore, prior authorization may involve demonstrating that the medication is being used to treat an obesity-related medical problem, such as high cholesterol or high blood pressure.
Additionally, prior authorization may be influenced by the type of medication prescribed. For example, some employers choose to exclude GLP-1 drugs from employer-sponsored health plans. Patients may wish to check the FDA Drug Shortages List before starting a medication like a GLP-1 agonist to ensure they can reliably obtain refills.
It is important to note that even with insurance, weight loss medications can be costly, and coverage may be discontinued, leading to patients stopping their treatment. Patients whose insurance stops covering their weight loss medication may consider generic versions of older drugs, which tend to be more affordable.
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Some employers exclude GLP-1 drugs from health plans
The decision to cover GLP-1 drugs for weight loss is a nuanced one for employers, and some choose to exclude them from their health plans. The drugs come with a high price tag, typically costing between $1,000 and $1,500 a month, and are not designed for short-term use. This means that employers could be faced with a long-term expense, with no long-term data on effectiveness and potential side effects.
The high cost of GLP-1 drugs is straining employer healthcare budgets, and with several more expected to hit the market by 2026, costs for employer health plans are likely to continue to rise. This is a significant concern for employers, with 38% of HR leaders surveyed by Accolade citing the costs associated with GLP-1s as a potential barrier to providing coverage.
However, there is increasing employee demand for these drugs, and they have been linked to effective weight loss and treating obesity, a chronic illness that carries a price tag of around $173 billion annually, according to the CDC. In addition, treating obesity could have a ripple effect, improving patients' overall health and potentially reducing downstream costs.
Some employers are considering various coverage and management strategies for GLP-1 drugs, such as prior authorization, limiting coverage to certain individuals, and setting higher cost-sharing requirements. Nearly all (99%) of the employers that are covering GLP-1 drugs plan to keep covering them next year, according to the Accolade survey.
While the majority of companies that cover these drugs do require insured members to meet certain requirements before coverage is approved, such as prior authorization, using step therapy, and specific eligibility requirements.
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Frequently asked questions
Payers tend not to cover weight loss medications. This includes commercial insurers as well as Medicare and Medicaid.
Many insurers and employers who sponsor health coverage consider weight loss a cosmetic need rather than a medical one. Medicare, for instance, is barred from covering weight loss medication due to past safety concerns.
Some weight loss medications include Wegovy, tirzepatide, semaglutide, fen-phen, and GLP-1 agonists.
Potential side effects of weight loss medication include nausea, vomiting, diarrhea, dizziness, mild tachycardia, and headaches. There are also concerns about a heightened risk of complications with anesthesia.
Weight loss medications can be expensive, with a month's supply costing $1,300 or more.
