What insurance plans cover weight loss medication?

Insurance coverage for weight loss medication

There is no coverage for obesity management medications for patients with Medicare or Medicaid. You may be able to get Medicare to cover GLP-1 medications if they’re prescribed for another health condition, such as diabetes. However, Medicaid coverage will depend on the state in which you live.

Last year, 18% of companies with 200+ employees covered GLP-1 medications for weight loss.

When discussing commercial insurance coverage for weight loss medications, you also need to take your employer into account. “When people hear insurance isn't covering their GLP-1 medication, they're usually confused because there's often more going on behind the scenes,” Ramzy Ladah, a personal injury lawyer in Nevada, said.

“It's not always about health — it's a numbers game. Companies weigh immediate costs against potential long-term benefits, and unfortunately, GLP-1 medications can end up on the chopping block,” Ladah said. In other words, when companies pick their insurance plan, they can have a lot of say over what’s included. If a drug like GLP-1 is expensive, the company may choose not to cover it.

Navigating insurance coverage

Navigating insurance for medications like GLP-1s is rarely straightforward, according to Ladah. “It's never just about the medicine itself,” he said. “It's always wrapped up in complex rules and fine print that most people only discover when they're facing a denial at the pharmacy counter.”

“Patients may have coverage of medications such as Ozempic or Mounjaro, but this is almost always exclusively for patients with a diagnosis of type two diabetes,” Stombaugh said.

The best way to know if obesity medications are covered for you is to call the phone number on the back of your insurance card or review the company’s drug formulary, according to Stombaugh. Specifically, look for coverage of medications such as Wegovy, Zepbound, Saxenda, Contrave, Qsymia or phentermine (covered by Kaiser Permanente, Blue Cross Blue Shield and others).

Barriers to coverage

Even if your benefits include coverage for obesity treatment, you may need official authorization before that medication is covered, according to Stombaugh. “The goal is to ensure that patients meet criteria for the use of these medications,” she said. However, individual plans vary on coverage criteria.

• Step therapy: This can be one barrier to getting coverage. “If the medical treatment of obesity is covered, step therapy may be required, such that patients are required to take an oral weight loss medication options like Qsymia, Contrave or phentermine and ‘fail it,’ before there is coverage of injectable weight loss medications, like Wegovy or Zepbound,” Stombaugh explained.
• Coverage limits: Something else Ladah sees frequently is insurance companies limiting coverage to a set period, such as six months. They reason that the GLP-1 medication either should show results quickly or because using them longer gets expensive fast. “If someone's condition requires longer treatment, they're usually stuck appealing denials or footing the bill themselves, which can put stress on both patients and providers,” Ladah explained.
• BMI requirements: You also might need to meet certain criteria for coverage. “Typically patients will need to have a body mass index (BMI) of 30 or higher or a BMI of 27 or higher with a weight-related comorbidity, in order to meet criteria for these medications,” Stombaugh said. If you’re denied coverage, don’t wait to file an appeal. You might need a letter from your healthcare provider.

» RELATED: How to get weight loss medication online

Maximizing your insurance benefits

Make sure you understand what your health insurance company does — or doesn’t — cover for weight loss before your appointment. “It’s frustrating for patients and physicians alike, when you have mutually agreed upon a treatment plan, only to realize the prescribed medication is not covered by your insurance,” Stombaugh explained.

Discounts and programs

You can use manufacturer savings cards for weight loss medications like semaglutide and tirzepatide. Some manufacturers also have patient assistance programs where you can get free medication if you qualify. These can lower your out-of-pocket costs.

Using your HSA or FSA

Health savings accounts (HSAs) or flexible spending accounts (FSAs) are options for some people. But there are some caveats. Things can get tricky when it comes to HSAs, Ladah said. “Yes, these medications are often eligible purchases under HSAs, but it depends on how your doctor writes the prescription.”

For instance, if your provider prescribes medication for diabetes or other weight-related health conditions, reimbursement from HSA is pretty straightforward. But if it’s prescribed for weight loss alone — especially if your insurance company considers its use “cosmetic,” the HSA might reject it.

• Health savings accounts: Running GLP-1 medications through your insurance prescription plan first can sometimes make things more expensive than paying cash upfront from your HSA. “I've seen situations where paying cash with HSA funds directly at the pharmacy was cheaper than running the transaction through insurance — because insurance companies have negotiated different price structures that can sometimes inflate the price you ultimately pay,” Ladah explained.
• Flexible savings accounts: FSAs have strict documentation requirements, according to Ladah. You need documentation of medical necessity from your provider (including clear diagnosis and prescription details) or the claim can get rejected. They also have strict deadlines — you either spend the money by the end of the year or lose it completely.

Alternative options if insurance doesn't cover

If your insurance benefits don’t cover obesity treatment, there are still some good options. Stombaugh outlined several alternatives, such as oral weight loss medications and cash pay. Besides GLP-1 agonists, there are other oral medications approved by the U.S. Food and Drug Administration (FDA) for weight loss, including:

• Phentermine/topiramate (Qsymia)
• Naltrexone/bupropion (Contrave)
• Orlistat (Xenical, Alli)

Contrave and Qsymia are each a combination of two medications. Stombaugh said it’s common for obesity medicine providers to also prescribe these individually, and these individual options are often covered by insurance.

Paying cash for these are cheaper than the GLP-1 agonists. According to Stombaugh, Contrave and Qsymia are each about $100 per month. In contrast, semaglutide costs $1,349 for a month's supply without insurance at the time of publication and tirzepatide costs $1,086.

Stombaugh recommended bupropion and naltrexone, or phentermine and topiramate, as more affordable alternatives. There is one over-the-counter (OTC) option that’s currently FDA-approved, which is orlistat under the brand name Alli. But Stombaugh warned there are no OTC medications or supplements that have shown clinically-significant effects for treating obesity.

Lifestyle changes

In any weight loss program, lifestyle changes are an important part, Stombaugh said. Combining lifestyle changes with obesity medication can give better results compared to either one alone. A comprehensive weight management program includes nutrition counseling, physical activity guidance, stress management, sleep evaluations and potential treatment for other health concerns.