Health Insurance Resources
It’s not ethical, but it’s perfectly legal for health insurance companies to exclude coverage for anti-obesity medications and obesity treatment (medical office visits that address weight). Understanding what your policy covers and excludes is vital when hoping to use health insurance for your treatment
Sadly, most health plans in our area DO NOT cover anti-obesity medications. If this is the case, no amount of pleading from our end (in the form of prior authorizations or appeals) will convince them. Trust us, we have tried and tried and tried…
If you are interested in using one or more anti-obesity medications as part of your treatment, before coming in for your first visit, it’s important to understand your coverage. The prescribe and pray method (having us send a prescription to your pharmacy, hoping it will work) usually results in frustration and means you have to wait until your next visit to discuss alternatives.
Steps to Figuring Out Your Coverage:
1) Get access to your plan’s formulary. You should be able to access this from your plan’s website or from your HR department
2) Search the formulary for Wegovy, Saxenda, Qsymia, Contrave and Zepbound (this doesn’t mean we are going to prescribe any of these medications – we are just trying to determine if any are covered!)
3) Find out what your portion of the cost will be for each one. This may be listed as a copay tier or fall under something called “shared cost.” If this isn’t disclosed on your insurance company’s website, call your carrier and ask a representative. Be persistent. Sometimes a medication is listed as “covered” but you are responsible for paying the entire cost.
**** Bring this information to your first visit so your clinician can use it to help guide decision-making about anti-obesity medications
If Your Plan Covers Anti-Obesity Medications:
If you and your clinicians decide that starting an anti-obesity medication is the best course of action and your insurance is willing to pay for the medication, chances are good that a prior authorization (PA) will be required before you can actually acquire the medication. If it’s required, a PA will automatically be started when the prescription is received by the pharmacy.
*** Please note: it can take up to two weeks (or more, in some cases) for PAs to process. This is not due to anything on our end and calling/emailing won’t cause them to process any faster!
***If a PA is denied because the plan doesn’t cover anti-obesity medications, no amount of appealing will cause them to reverse their decision (trust us, we’ve tried). If you want us to file an appeal on your behalf, we are happy to do it. However, because it takes a significant amount of time on our end, we charge $25 for filing the appeal – regardless of the outcome.
*** We DO NOT prescribe new anti-obesity medications between appointments (in response to phone calls or portal messages). Changes in medications require a face-to-face conversation with one of our Obesity Medicine Specialists, which means it must be done during a visit. This is one of the many reasons we recommend frequent visits at the onset of treatment.
*** If you have a plan other than BCBS or United (there are dozens!), chances are that the process of checking your formulary is VERY similar to the process described above. Watch one or both videos (they are very short) and then apply that information to your plan website!
About Ozempic/Semaglutide:
Semaglutide is the generic name for an anti-obesity medication that has recently gotten lots of public attention. Semaglutide exists in three forms:
- Ozempic (FDA-approved for treating type 2 diabetes)
- Wegovy (FDA-approved for treating excess weight)
- Compounded (not-FDA-approved for anything at all!)
If your formulary includes Ozempic, it DOES NOT mean it will be covered. Although earlier this year, many people were using it off-label to treat obesity, plans have put us strict guardrails around accessing this medication and it is only covered for patients with a diagnosis of type 2 diabetes (and lab evidence to support it).
Due to concerns about safety and lack of quality data, we DO NOT write prescriptions for compounded semaglutide. We have other tools in our toolbox for treating excess weight that have much better safety profiles.
If you have CVS Caremark
We have recently learned that some employers that use CVS Caremark and cover anti-obesity medications have opted into a program that, beginning November 1, 2023, will require all patients receiving these anti-obesity medications to get them via the CVS Caremark program. This is a brand-new program created by CVS and we have no idea what this program entails. Their marketing materials claim that participants will have access to a dietician and “provider oversight”, but at this point, we have no idea what this means, and they have not advertised anything about utilizing clinicians with advanced training in Obesity Medicine, which is sad (but not surprising). We do know that the marketing materials aimed at the employers claim that they will try and dissuade patients from utilizing anti-obesity medications. If you have CVS Caremark, look into this right away and if you disagree with it, talk to your employer/HR department about opting-out.
If you want to appeal to your employer to cover anti-obesity medications
Most employers that provide their employees with a health insurance policy want their employees to be healthier. Not only because it’s good for their people’s well-being overall, but also because employers offering health insurance are required to pay at least half of the premiums. Having healthier employees saves them money too. Most employers can’t afford to broadly cover all anti-obesity medications – with the amount of med spas writing prescriptions and online companies offering medications without oversight, the risk/benefit ratio simply doesn’t support it. However, they may be willing to help with the cost for an employee participating in an evidence-based program deployed by clinicians with advanced training in Obesity Medicine – who utilize anti-obesity medications in a prudent way, as part of a comprehensive program to improve health (and decrease healthcare costs). CLICK HERE to download a sample letter that you can provide your HR department to appeal for coverage.
