Tips for Getting Insurance Coverage for GLP-1 Obesity Medications

If you’ve looked into these medications, you might be wondering how to get your insurance to cover them or how to afford them if you are underinsured or uninsured. Here’s what you need to know and how to improve your chances of getting insurance approval.

How to Check if Your Insurance Covers GLP-1 Obesity Medications

But calling your insurance company is often the best way to check coverage and eligibility requirements. When you speak with an insurance representative, here are some questions to ask:

• Does my plan cover Wegovy or Zepbound for weight loss?
• What are the specific criteria I need to meet for coverage, such as BMI requirements and health conditions?
• Is prior authorization required?
• What documentation does my doctor need to submit?
• Do I need to try other weight loss methods first?
• What will my out-of-pocket cost be if approved?
• How long does the approval process take?

How to Submit a Prior Authorization Request

• BMI of 30 or higher
• BMI of 27 or higher with at least one weight-related health condition, such as high blood pressure or type 2 diabetes.

Small recommends having the following ready when submitting a request for coverage:

• Your BMI and recent weight history
• Medical records showing past attempts to lose weight
• Lab results, like fasting glucose, hemoglobin A1C, and cholesterol levels
• A letter from your healthcare provider explaining why the prescribed medication is medically necessary

Your provider’s office will usually handle the prior authorization process and send these documents to your insurance company for review. If approved, you’ll get a notification from your insurer letting you know how to fill your prescription. If denied, you have options.

Insurance Appeals

If your insurance denies coverage for a GLP-1 obesity medication, the first step is to call your health plan and find out why, says Brown. Some plans don’t cover weight loss medications at all, and if that’s the case, unfortunately, an appeal won’t change the outcome, she says.

In other situations, the denial may be because certain requirements haven’t been met yet. For example, some insurers require you to complete a three-month, physician-supervised weight loss program before approving the medication, says Brown. Once you complete those steps, your provider can resubmit the prior authorization request.

• Ask your provider to review your records to make sure everything that supports your need for the medication is clearly documented, says Small.
• Follow your insurer’s appeal instructions, which are usually included in the denial letter or on its website.
• Work with your provider to submit any additional supporting documentation.

Your provider can also request a peer-to-peer review, during which they speak directly with a healthcare reviewer or medical director from your insurance company to clarify details and advocate for your case. “In my experience with effective appeals and peer-to-peer review cases, success was always a result of clear, concise documentation and persistence with the argument,” says Small.

She adds that when your provider presents obesity treatment as part of managing a long-term health condition and explains how the medication can improve blood sugar, cholesterol, and weight over time, it helps strengthen your case for medical necessity.

Medicare and Medicaid

Medicaid coverage varies by state. Small notes that some state programs cover GLP-1 medications for weight management, while others don’t cover any weight loss drugs at all. “Others have a step therapy process in place, in which cheaper weight loss medications have to be tried first before they’ll cover GLP-1 medications,” says Brown.

Coverage rules can change depending on state funding and policy updates, so it’s best to check directly with your state’s Medicaid program to see what’s covered and what criteria apply.

The manufacturers of Wegovy and Zepbound offer savings programs, and information about signing up is available on their websites.

• Orlistat (Xenical)
• Phentermine (Adipex-P)
• Phentermine and topiramate (Qsymia)
• Naltrexone and bupropion (Contrave)
• Liraglutide (Saxenda)

Sasson suggests asking your provider about compounded GLP-1 medications, which can cost much less than brand-name versions. “A compounded version is one in which the GLP-1 is mixed with another drug, usually vitamin B12 or L-carnitine, and sold under the scientific name instead of the brand name,” he says.

Choosing the right medication depends on your health history, other medical conditions, and how well you tolerate potential side effects. Regardless of which medication you choose — or whether you use medication at all — lasting weight loss requires lifestyle changes, says Small. Working with a care team that includes a dietitian, behavioral counselor, and healthcare provider can set you up for long-term success.

Getting insurance coverage for GLP-1 medications for weight loss often means being proactive and persistent. Here’s how you can advocate for yourself:

• Go prepared. “I always encourage patients to do their research on weight loss [drugs] and lifestyle modifications before the appointment, so they are aware of potential side effects, risks, and benefits of the medication,” says Small. Also, be sure to understand your insurance plan’s coverage criteria and whether you meet them.
• Bring documentation. Keep a log of your weight history, blood pressure readings, and lab results from the past 6 to 12 months. This helps show your efforts and track trends over time, says Small.
• Be clear about what you’ve tried. Talk to your healthcare provider about the steps you’ve taken, such as changes to your diet, weight loss surgery, exercise habits, or behavior, and be honest about what hasn’t worked. This information can strengthen your case for coverage.
• Ask about other covered health conditions. Many insurance plans cover GLP-1s for other FDA-approved conditions, even if they don’t cover them for weight loss alone. For example, Brown notes that up to 75 percent of people with significant obesity have sleep apnea, and Zepbound is FDA-approved to treat moderate to severe obstructive sleep apnea.

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   “If a patient has sleep apnea, it’s much easier to get approval for GLP-1 therapy for sleep apnea than for weight loss,” she says.
  
• Stay open to alternatives. If you don’t meet the criteria for a GLP-1, ask about other medications or medically supervised weight loss programs, says Small. Some accept insurance or offer reasonable self-pay options.
• Stay persistent. Even if one insurance company denies your request, circumstances change. Laws and FDA approvals continue to evolve, and insurance coverage for these medications could become more available in the future.

• Insurance coverage for GLP-1 obesity medications like Wegovy and Zepbound depends on your plan and whether the medications are prescribed for weight loss or another FDA-approved health condition.
• To check insurance coverage, review your plan’s summary of benefits, call your insurance provider, and ask about eligibility requirements. Your healthcare provider can submit the necessary documentation for a prior authorization request.
• If your insurance denies coverage, work with your healthcare provider to appeal and provide additional documentation to support your request.
• Even if GLP-1s aren’t an option right now, other prescription medications and medically supervised programs are available. New FDA approvals or medical criteria changes could make coverage possible in the future.