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December 18, 2023

Does Insurance Cover Weight Loss Medication?

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With weight loss medications proliferating and attracting ample media attention, more patients are asking about their costs. Several newer medications, mainly GLP-1 receptor agonists, have been introduced. Some are diabetes treatments prescribed off-label, and, in some cases, manufacturers have rebranded and gained FDA approval specifically to treat obesity. For example, in November 2023, the FDA approved Zepbound, a brand name for the drug tripeptide, already sold as Mounjaro, to treat diabetes.

While some older weight loss medications have available generics, making them more affordable, the newer drugs can come with a hefty price tag. As of an October 2022 report from the Institute for Clinical and Economic Review, a month's supply of Wegovy (semaglutide) ran $1,300. High costs leave patients asking, does insurance cover weight loss medication?

Since drugs like tirzepatide and semaglutide are meant to be taken indefinitely, starting one is a financial commitment. By helping patients find answers to their questions about cost and coverage, you can make the best possible decisions regarding their treatment for the disease of obesity.

Does Insurance Cover Weight Loss Medication?

Payers tend not to cover weight loss medications. This goes for commercial insurers as well as Medicare and Medicaid. In fact, Medicare is prohibited by law from covering them. Many insurers and employers who sponsor health coverage consider weight loss a cosmetic need rather than a medical one. (The AMA disagrees, but more on that later.)

Whether any given payer covers these medications can vary from one plan to another. Some plans, from some payers, cover certain weight loss medications. Some will do so with prior authorization. Others will not cover them at all. A patient will need to check the details of their own plan.

Why Medicare Doesn't Cover Weight Loss Medication

Medicare is barred from covering weight loss medication by law due to past safety concerns. In 2003, Medicare part D was launched to help manage prescription drug costs as part of the Medicare Modernization Act. This legislation was born from the fallout from fen-phen in the 1990s. Fen-phen, a combination of fenfluramine and phentermine, led to rapid weight loss and received comprehensive media coverage as a "miracle" drug. It was later found to cause heart valve damage and was removed from shelves in 1997. A s a result, the federal government disallowed Medicare from covering drugs viewed as having the risks outweigh the benefits, namely cosmetic benefits.

In 2010, the Affordable Care Act expanded coverage by government and commercial insurers to defray the costs of interventions like bariatric surgery to treat obesity. However, it did not address weight loss medications.

Pressure on Insurance Companies

A decade ago, the American Medical Association ratified a resolution officially calling obesity a disease, a position that the OMA shares. It follows, then, that they consider weight loss drugs a medical treatment. At a meeting in November 2023, the AMA passed a resolution saying it will "urge all payers to ensure coverage parity for evidence-based treatment of obesity, including FDA-approved medications without exclusions or additional carve-outs." You can read the text of the AMA resolution here.

Another argument for coverage is obesity's link to cardiovascular and other related diseases. For example, data on Wegovy shows that it offers cardiovascular benefits. Further research shows that treating obesity helps to prevent diabetes and heart disease. These preventative approaches would, in theory, save money for the payers over time.

The U.S. Congress has pushed for Medicare to cover weight loss medications, most recently with the Treat and Reduce Obesity Act of 2023 (H.R. 4818 and S. 2407). The Congressional Budget Office (CBO) has been working to provide information to Congress on the potential for preventive medical care—which could include obesity treatment—to save money.

The Congressional Budget Office (CBO) has stated, "The developing market for [anti-obesity medications] could significantly affect health care spending and the federal budget." They contend that passage of the Treat and Reduce Obesity Act would increase costs for anti-obesity medications (i.e., because more people would use them) but reduce federal costs for other related health issues.

Take a look at our advocacy Toolkit for talking points and advice on contacting policymakers about supporting coverage for weight loss medications.

Who Qualifies for Weight Loss Medication?

With obesity rates higher than ever, it's estimated that nearly half the U.S. population is eligible for weight loss medications. Some medications are approved for people with obesity, while some are also approved for people classified as having overweight but not obesity.

To use Wegovy as an example again, it is approved for those with a BMI of 30 or greater or with a BMI of 27 or greater with comorbidities such as high blood pressure, diabetes, or high cholesterol. Zepbound is approved for those with a BMI of 30 or greater.

Age is also a factor. Zepbound is approved only for adults, but as of this writing, it is being studied for use in adolescents. Some GLP-1 agonists, as well as other medications like orlistat and Qsymia, are approved for ages 12 and older. Phentermine is approved for adolescents 16 and older. Other options may be available for children with certain rare genetic diseases that cause obesity.

Some providers have prescribed GLP-1 agonists approved for diabetes off-label, but pharmaceutical companies are increasingly pursuing approval of the drugs specifically for weight loss.

The Growing Popularity of Weight Loss Medication

You may have noticed an increased interest in weight loss medications among your patient population. The statistics back up that perception. Semaglutide was a major focus of Trilliant Health's 2023 "Trends Shaping the Health Economy." The report reveals that sales of semaglutide (including Ozempic and Wegovy) totaled $10.7B in 2021. From 2020 to 2022, prescriptions for these medications increased by 300%. This includes prescriptions for diabetes and weight loss, but the trend is striking.

According to the CBO, sales of anti-obesity medications stood at $1.1 billion for the second quarter of 2023. If that number already sounds high, consider that it represents a 65 percent increase over the previous quarter.

Celebrity praise for these medications helps fuel public interest. Those who have spoken in favor of GLP-1 agonists include Oprah Winfrey, Tracy Morgan, and Amy Schumer.

Safety Concerns with Stopping GLP-1 Agonists

While many people start these medications, not all stay on them. A July 2023 report states that around two-thirds quit within a year. The patients in this study had their medications covered by insurance, so cost may not have been a factor. Reasons patients give for stopping include reaching a plateau in weight loss, inability to tolerate side effects, or even inability to get the medication due to shortages. There have, however, been anecdotal reports of patients who stop taking one of these medications because their insurance stops covering it or they switch to a new insurance company (say, due to a job change) and can no longer get coverage.

Potential side effects of GLP-1 agonists include nausea, vomiting, diarrhea, dizziness, mild tachycardia, and headaches. There are concerns about a heightened risk of complications with anesthesia for people using these drugs. The American Society of Anesthesiologists recommends forgoing medication doses for a day to a week before undergoing anesthesia, depending on dosing frequency.

Risks of Stopping GLP-1 Agonists

Besides those risks, there are also risks of going off the medications. A study published in Diabetes, Obesity & Metabolism looked at the effects of stopping semaglutide. This extension of a clinical trial study of 1,961 people followed 327 of them for an additional year. The sample included participants who had taken semaglutide 2.4 mg (along with lifestyle interventions) and those who were given a placebo. Investigators measured the effects on weight, as well as blood sugar levels, blood pressure, cholesterol levels, and C-reactive protein, which may indicate heart disease risk.

After one year, both groups regained at least some weight. The semaglutide group, initially losing an average of 17.3% of their body weight, returned to 5.6% below their starting weight. Improvement in blood pressure was also reversed. Blood sugar and cholesterol levels retained their improvement. The investigators concluded that "ongoing treatment is required to maintain improvements in weight and health."

How to Help Patients Afford Weight Loss Medications

Given that the costs of many weight loss medications are high, insurance often does not cover them, and stopping stymies their benefits, how can you best help patients who want to take them?

First, before starting a patient on a GLP-1 agonist, you may wish to check the FDA Drug Shortages List to ensure the patient can reliably get refills. Then, you and the patient can turn to cost.

Some recommendations for patients whose insurance won't cover weight loss medications are the same as for other treatments. One option is to consider generic versions of older drugs, such as bupropion, liraglutide, or orlistat.

If a GLP-1 agonist is, in fact, the best option for a patient, they can comparison shop. GoodRx lets patients compare prices across pharmacies and look for coupons. Similar services exist at the state level in certain states. Patients on Medicare with limited resources may be able to get help through the Medicare Part D Extra Help program.

Patient Assistance Programs for Weight Loss Medications

Many drug makers offer patient assistance programs that include discounted pricing. The following links lead to patient assistance programs aimed to help defray the costs of these medications:

Saxenda (Novo Nordisk)

Wegovy (Novo Nordisk)

Zepbound (Lilly).

Time will tell whether insurers or the U.S. government adjust their stance and choose to start covering weight loss medications, as the popularity of these drugs seems not to be disappearing anytime soon.

Wilding JPH, Batterham RL, Davies M, Van Gaal LF, Kandler K, Konakli K, Lingvay I, McGowan BM, Oral TK, Rosenstock J, Wadden TA, Wharton S, Yokote K, Kushner RF; STEP 1 Study Group. Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes Metab. 2022 Aug;24(8):1553-1564. doi: 10.1111/dom.14725. Epub 2022 May 19. PMID: 35441470; PMCID: PMC9542252.