Will your health insurance cover weight-loss medications? It depends on several factors, including where you live

Minneapolis, MN, May 08, 2024 (GLOBE NEWSWIRE) -- Interest in medications prescribed for weight loss is skyrocketing, sparking consumer questions about whether health insurance covers these often expensive drugs. Today, medicareresources.org explains that coverage depends largely on an individual’s health status, the type of coverage they have, and also where they live.

“Medical practitioners have seen a lot more interest lately in medications that promote weight loss, like Wegovy and Ozempic, and patients want to know if they’re covered and how much they’ll have to pay out-of-pocket,” said Dr. Tanya Feke, a health policy analyst for medicareresources.org. “These are FDA-approved medications, so there is some confusion for patients when they find out they may not be covered, especially by Medicare.”

How Medicare covers weight-loss medications

Medicare Part D prescription drug coverage will only cover medications that are prescribed for the treatment of specific medical conditions, such as diabetes or cardiovascular disease. It will not cover the medications, which are also known as GLP-1 agonists, for weight loss alone. 

These GLP-1 receptor agonists are covered by Medicare when they are prescribed to treat Type 2 diabetes: Mounjaro, Ozempic, Trulicity, Rybelsus and Victoza. Wegovy, a medication with the same active ingredient as Ozempic and Rybelsus, is also now covered by Medicare if prescribed to reduce the risk of serious cardiovascular events in people who are known to have cardiovascular disease and are also overweight or obese – a new development that is fueling added interest in the coverage landscape for weight-loss drugs. Similar medications that are branded specifically for weight loss - Saxenda and Zepbound - are not covered at this time. 

“The reason the medication is being prescribed is the No. 1 determinant of whether or not it will be covered by Medicare, and that reason can impact coverage under other types of plans as well,” explained Feke.

How other insurance covers weight-loss medications

For consumers with coverage through an employer or through the Affordable Care Act  (ACA) Marketplace, coverage of GLP-1 agonists will largely vary by state and by plan.

“Consumers shouldn’t assume their health insurance covers weight-loss medications. Several factors impact whether a weight-loss medication will be covered,” said Louise Norris, health policy analyst for healthinsurance.org. “You may have coverage for these medications because you’ve been diagnosed with diabetes or a cardiovascular risk, or because you live in a state like New Mexico, where Marketplace plans and some employer plans cover medications prescribed for weight loss alone.”  

Here is how weight loss medications are currently covered:

• Marketplace coverage: ACA plans are not required at the federal level to cover weight-loss drugs. Each state sets its own coverage standards through their Essential Health Benefits (EHB) benchmark plan. Most current EHB benchmark plans do not include coverage for anti-obesity medications, but some do. If the drug is prescribed to treat type 2 diabetes or to reduce cardiovascular risk, it’s much more likely to be covered. But each plan sets its own formulary (covered drug list) so a plan might cover some GLP-1 agonists to treat diabetes, but not others.
• Employer-sponsored coverage: The majority of employer-sponsored health plans in a 2023 survey covered GLP-1 agonists for the treatment of diabetes, but only about a quarter do so for weight loss. Coverage depends in part on whether the plan is self-insured or purchased by the employer in the large group or small group market. Small group plans are governed by the coverage standards each state sets through its EHB benchmark plan, but self-insured plans and large group plans are not. Large group plans are subject to certain state mandates, while self-insured plans are not. If a large employer opts to purchase coverage from an insurer, the coverage specifics will depend on the options that insurers make available in that area. But if the employer opts to self-insure, they can design their own coverage. 

“If coverage for weight-loss medications is important to you or your family, take advantage of the next annual open enrollment period – or check whether you’re eligible for a special enrollment period now – to shop for a plan that might meet those needs,” said Norris. “But be aware that coverage of GLP-1 agonists in the individual market can depend in large part on the reason the drug is being prescribed, just as we see for employer-sponsored plans and Medicare.”

Medicareresources.org has been an online source of in-depth information about Medicare for consumers since 2011. The site, owned by Healthinsurance.org, LLC, provides an overview of the basics of Medicare coverage options, enrollment and eligibility; coverage FAQs; state-specific Medicare information; and a glossary of Medicare terms. Medicareresources.org is not connected with or endorsed by the U.S. government or the federal Medicare program.

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Source: medicareresources.org