Will insurance cover prescription weight loss injectables?

Contact: Jennifer Bowen
(334) 269-3550

8/6/2024

You’ve probably heard of injectable drugs that are used to treat diabetes. You've also probably heard about weight loss and obesity-specific injectable medications. These medications usually contain either semaglutide or tirzepatide, which are GLP-1 receptor agonists. They work by reducing blood sugar, reducing appetite, and signaling fullness.

Does insurance cover these medications for weight management? That depends.   

When does insurance cover injectables?  Mounjaro (tirzepatide) and Ozempic (semaglutide) are often praised on social media for helping people lose weight. However, those drugs are only FDA-approved to treat type 2 diabetes (along with diet and exercise), not obesity.  

While some providers may prescribe them off-label for other conditions like obesity, they usually aren’t covered by insurance unless a person has a type 2 diabetes diagnosis.  

Some employers choose to exclude GLP-1 drugs from employer-sponsored health plans. Some insurance plans require prior authorization before approval. It is up to each insurer and its chief medical officer to decide if these medications will be covered. Contact your insurer to find out if it excludes weight loss injectables from coverage. Even with insurance, weight loss injectables can still cost hundreds of dollars per month. 

What about injectables approved for weight loss?  The FDA recently approved versions of GLP-1 medication - including Wegovy (semaglutide), Saxenda (liraglutide), and Zepbound (tirzepatide) - for chronic weight management. According to the FDA, these prescriptions are meant to be used along with a reduced-calorie diet and exercise to manage weight and reduce the risks of obesity-related conditions. However, your health insurer may not cover these drugs unless you have an obesity-related medical problem, such as high cholesterol or high blood pressure. A high BMI that indicates you are obese or overweight may not be sufficient.  

How much do injectable drugs cost without insurance?  According to the KFF and the Institute for Clinical and Economic Review (ICER), some injectable drugs intended for weight management can cost $1,300 or more for a month’s supply. While drug manufacturers sometimes offer discount programs, consumers are often left paying hundreds of dollars out of pocket for their prescriptions. Legally, Medicare cannot cover weight loss medications.  

I have a prescription. How can I appeal my health insurer’s denial of weight loss injectables? If your doctor prescribed medication 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 health care provider (doctor, hospital, etc.) believe are medically necessary. There are two kinds of appeals - internal appeal and external review. You can learn how to file the appeals here. 
 

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