Haris Ashley
Weight loss medications can be expensive, often costing upwards of $1,000 per month. Many insurance companies do not cover these drugs, leaving patients to pay out of pocket. Medicare, for example, is barred by law from covering weight loss medications due to past safety concerns. However, there are some options for patients whose insurance won't cover weight loss treatments. These include considering generic versions of older drugs, using services like GoodRx to compare prices and find coupons, and looking into patient assistance programs offered by drug manufacturers. While employer interest in covering weight loss medications is rising, the majority of employer health plans do not currently offer coverage for these treatments.
| Characteristics | Values |
|---|---|
| Why insurance doesn't cover weight loss medication | Weight loss is considered a cosmetic need rather than a medical one |
| What to do if insurance doesn't cover weight loss medication | - Consider generic versions of older drugs such as bupropion, liraglutide, or orlistat |
| - Compare prices across pharmacies and look for coupons | |
| - Patients on Medicare with limited resources may be able to get help through the Medicare Part D Extra Help program | |
| - Drug makers often offer patient assistance programs with discounted pricing | |
| - Contact the manufacturer to check eligibility for savings programs | |
| - Appeal the insurer's denial of coverage |
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What You'll Learn
Consider generic versions of older drugs
If your insurance does not cover weight-loss medication, one option is to consider generic versions of older drugs. While newer drugs can be expensive, older weight-loss medications often have available generics, making them a more affordable option. For example, the monthly cost of semaglutide (including Ozempic and Wegovy) is $1,300. In contrast, older drugs like bupropion, liraglutide, or orlistat may be more affordable.
Generic drugs are often cheaper than their brand-name counterparts because they do not have to recoup the costs of research, development, and marketing. Additionally, competition from multiple manufacturers can drive down prices. This can make generic versions of older weight-loss drugs a more cost-effective option for those whose insurance does not cover weight-loss medication.
It is important to note that not all older drugs will have generic versions available, and even if they do, the cost may still be significant. However, comparing prices across pharmacies and looking for coupons or discounts can help make these medications more affordable. GoodRx, for instance, is a service that allows patients to compare prices and look for coupons. Similar services are also available at the state level in certain US states.
It is also worth noting that Medicare, by law, cannot cover weight-loss medication due to past safety concerns. This includes Medicare Part D, which was launched to help manage prescription drug costs. Therefore, if you are on Medicare, you may need to explore other options, such as patient assistance programs offered by drug manufacturers or the Medicare Part D Extra Help program.
In conclusion, considering generic versions of older drugs is one strategy for accessing weight-loss medication if your insurance does not cover it. While newer drugs can be costly, older medications may have more affordable generic options. By comparing prices and taking advantage of available discounts, you may be able to find a treatment option that fits your budget.
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Compare prices across pharmacies
If your insurance doesn't cover weight-loss medication, one option is to compare prices across pharmacies. The US has the highest rate of obesity among its peer nations, with a third of adults suffering from obesity. This high demand for weight-loss drugs can make them very expensive, with some costing over $1300 for a month's supply.
GoodRx is one option for comparing prices across pharmacies and finding coupons to help offset the cost. Similar services exist at the state level in certain states. Additionally, many drug manufacturers offer patient assistance programs that include discounted pricing.
For example, GoodRx has partnered with InsideRx and Currax Pharmaceuticals LLC to reduce the price of Contrave (naltrexone/bupropion), a popular opioid antagonist/atypical antidepressant combination used to promote and maintain weight loss in obese adults or overweight adults with weight-related medical problems. Phentermine (Adipex-P) is another inexpensive drug that can be used to decrease appetite and promote weight loss. It is available in generic and brand versions and can be purchased with pharmacy coupons.
Other weight-loss drugs, such as Wegovy (semaglutide), are not covered by most Medicare and insurance plans but offer manufacturer and pharmacy coupons to help with the cost. A month's supply of this medication can cost around $1300. Plenity is another weight management drug with no generic alternatives that may be covered by Medicare or insurance, but pharmacy coupons can help offset the cost.
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Look for coupons and patient assistance programs
If your insurance does not cover weight loss medication, you can look for coupons and patient assistance programs to help with the cost.
Many drug manufacturers offer patient assistance programs (PAPs) that provide patients with their medications at no cost or a reduced cost. If you qualify, you may receive your medication for free. However, not every drug has a patient assistance program. For example, the manufacturer of Wegovy, a weight loss medication, offers a savings program with options for people with and without insurance. You can also visit Optum Perks for price estimates for Wegovy when you use coupons from the site. These coupons cannot be used with insurance copays or benefits.
Prescription discount cards, like SingleCare, can also help reduce the cost of many drugs. For example, SingleCare can reduce the cost of a one-month supply of phentermine from $40 to $5.42.
Additionally, manufacturer copay cards are savings offered directly by the drug maker, typically on newer, brand-name medications. Generally, you must have private or commercial insurance with coverage to qualify for a savings card. These cards can be beneficial if insurance covers part of the medication's cost.
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Appeal your health plan's denial of benefits
If your insurance denied coverage for weight loss medication, you have the legal right to appeal their decision. Appeals work—patients who appealed directly to their insurance provider experienced a success rate of 39-59%. Denials are also often issued by mistake, with a computer making the initial decision without considering your personal health situation.
Appeals generally consist of a formal letter addressed to your insurance company, explaining why a medication should be covered and why the initial denial should be overturned. You can use a free appeal template or get help from services like Honest Care, which simplifies the appeals process by writing an appeal letter and supporting documents on your behalf.
If you are denied coverage for specific weight loss drugs like Ozempic, Mounjaro, Wegovy, or Zepbound, you can submit an appeal to your insurance company. These drugs are often praised for their weight loss benefits, but they are only FDA-approved to treat type 2 diabetes and are not typically covered by insurance unless the patient has diabetes.
Medicare is barred from covering weight loss medication by law due to past safety concerns. However, Medicare Part D was launched in 2003 to help manage prescription drug costs as part of the Medicare Modernization Act. Patients on Medicare with limited resources may be able to get help through the Medicare Part D Extra Help program.
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Contact your insurer to understand coverage
Contacting your insurer to understand their coverage criteria is a crucial step in navigating weight loss medication coverage. Here are some key considerations:
Understanding Coverage Policies
Firstly, familiarize yourself with the insurer's policies on weight loss medication coverage. This includes knowing which specific medications are covered and under what circumstances. Some insurers may cover certain drugs only for treating diabetes or other obesity-related medical problems, such as high cholesterol or high blood pressure. Understanding these nuances will help you assess your eligibility for coverage.
Prior Authorization and Step Therapy
Some insurance plans require prior authorization or pre-approval before covering weight loss medications. This means you may need to meet certain eligibility criteria or undergo specific procedures before receiving coverage. Additionally, some insurers may require step therapy, where patients must first try lower-cost medications before progressing to more expensive options. Understanding these requirements will help you navigate the path to getting coverage for your prescribed treatment.
Understanding Exclusion Policies
It is important to know if your insurer explicitly excludes weight loss medications or injectables from coverage. Some employers, for instance, choose to exclude GLP-1 drugs from their health plans. Understanding these exclusions will help you determine if alternative options, such as generic versions of older drugs, may be more feasible for coverage.
Exploring Discount Programs
Even if your insurer doesn't cover weight loss medications, they may offer discount programs or savings initiatives to help reduce the financial burden. These programs can provide significant savings off the full retail price of medications. It is worth inquiring about such programs and carefully reviewing the eligibility requirements and restrictions.
Appealing Denials
If your insurer denies coverage for weight loss medication, remember that you have the right to appeal their decision. You can initiate an internal appeal or request an external review, particularly if you and your healthcare provider believe the medication is medically necessary. Understanding the appeals process can provide you with options for challenging a denial of coverage.
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Frequently asked questions
Firstly, you can consider opting for generic versions of older drugs, such as bupropion, liraglutide, or orlistat, which are more affordable. You can also use GoodRx to compare prices across pharmacies and look for coupons. Patients on Medicare with limited resources may be able to get help through the Medicare Part D Extra Help program, and many drug makers offer patient assistance programs with discounted pricing.
Payers tend not to cover weight loss medications due to the perception that obesity is a cosmetic issue rather than a chronic disease. Medicare, for example, is barred from covering weight loss medication by law due to past safety concerns and the fact that the long-term effects of these drugs are not yet fully known.
Yes, there are some indications that insurers and lawmakers may be coming around to the idea of covering weight loss drugs. In 2021, House lawmakers introduced The Treat and Reduce Obesity Act, which would have allowed the federal government to expand Medicare Part D coverage to include weight loss medications. While this did not receive a vote, employer interest is rising, and employee benefits experts say it's a matter of when, not if, more company insurance plans will cover weight loss treatments.
