Challenges With Insurance Denials for Weight Loss Medications

Over 40% of Americans have been diagnosed with obesity, and its prevalence is continuing to rise in the United States. Obesity is linked to other chronic conditions such as heart disease, diabetes, and stroke. A class of medications known as glucagon-like peptide-1 (GLP-1) receptor agonists have been shown to help manage obesity effectively. This article explores insurance coverage of these medications and your options for overcoming insurance denials.

What are glucagon-like peptide-1 (GLP-1) receptor agonists?

Glucagon-like peptide-1 (GLP-1) receptor agonists are medications with demonstrated effectiveness in managing diabetes. The medicines work by imitating the hormone glucagon-like peptide 1 and increasing insulin levels when your blood sugar is elevated. In recent years, they have also been shown to be effective in weight loss.

GLP1-1 agonists help slow digestion, causing you to feel fuller longer after a meal. As a result, you will eat less and ultimately lose weight. Currently, there are three injectable drugs on the market that the Food and Drug Administration approves to assist in weight management and aid weight loss. Those medications are liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound).

In addition to providing weight loss benefits, these medications have also been linked to improved cardiovascular outcomes (liraglutide and semaglutide) in patients with diabetes. These factors have led to an increased demand for these agents. However, these medications can be expensive without prescription drug coverage. The table below summarizes important information about the medications, including cost.

Summary of GLP-1 Medications for Weight Loss:

What’s the current situation of insurance coverage for GLP-1s?

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The American Medical Association began acknowledging obesity as a chronic condition in 2013. However, obesity is still primarily considered a behavioral problem. Additionally, before GLP-1 agonists, many medications on the market showed minimal effectiveness and were linked to significant adverse effects. These issues have caused hesitancy among insurance companies to cover these medications. Although more insurers are starting to cover these medications, specific challenges exist. Below is a general summary of the current state of some insurers.

• Commercial insurance plans. GLP-1 medications are covered by many commercial insurance plans, especially the larger insurers. However, patients must meet specific criteria to qualify for coverage. Some employer insurance plans also cover weight loss medications and utilize the prior authorization process to monitor utilization.
• Medicare. Weight loss medications are not covered by Medicare Advantage or Medicare Part D plans. However, Medicare does cover Mounjaro, Victoza, and Ozempic, the formulations of GLP-1s used to help manage diabetes.
• Medicaid. While several Medicaid programs cover GLP-1 medications for diabetes, many do not cover the drugs for weight loss. Coverage of these drugs for weight loss varies by state and may require prior authorization approval before Medicaid will pay for it.

You will likely need to meet specific criteria before your insurance company covers the cost of one of these weight-loss drugs. You should have attempted to make lifestyle changes to help with weight loss. Lifestyle changes can include eating healthier foods and increasing physical activity. Additionally, you may have to meet one of the following criteria:

• Have a BMI of 30 or higher
• Have a BMI of 27 or higher AND one or more obesity-related conditions such as high blood pressure, high cholesterol, heart disease, or diabetes
• Attempted lifestyle modifications for three to six months, but have not lost 5% of your total body weight

What if my insurance plan won’t pay for my medication?

If you are denied coverage by your insurance plan, you can try to convince your insurance company to pay for your medication through a couple of alternative methods. You can also seek assistance from the manufacturer in certain instances as well.

Prior authorization

One way insurance companies are attempting to manage the cost and utilization of these drugs is through prior authorization. Your insurance company may want to ensure that you have met specific criteria before paying for the medication. If prior authorization is required, your provider may have to submit paperwork to your insurance company for medical necessity before coverage can be granted. Review your plan and consult with your provider if a prior authorization is required to receive your medication.

Appeals process

If you feel that your insurance plan should cover your medication, you can appeal if your claim is denied. This is typically done by writing a letter to your insurance company. In the letter, you should thoroughly describe why you appeal the company’s decision. For instance, if you have tried several other weight loss medications and have not lost weight, you should include that in your letter.

Another scenario may be that you are unable to take other medications for weight loss due to being allergic to the medicine or it interacts with your other medications. This information should also be included in your letter. Lastly, include your contact information, policy details, information about the medication denied, and your medical provider’s contact information in your submission. Review your insurance policy for more details about your plan’s appeal process.

Patient assistance programs

If you need help reducing your copay or your plan does not cover the medication, you may qualify for discounts through the manufacturer. Norvo Nordisk (supplier of Wegovy), and Eli Lilly (supplier of Zepbound) both offer coupons to decrease your out-of-pocket costs. These savings can be provided to individuals with commercial insurance plans or those without insurance coverage. People enrolled in a governmental health plan, such as Medicare, are not eligible to participate.

Long-term weight maintenance

If you’re taking a GLP-1, it is very important to adhere to your medication regimen. Effective and sustained weight loss is most likely to occur with long-term use. If you repeatedly miss doses of your medication, you may not receive the full weight loss benefits. Furthermore, if you abruptly stop taking your medication, you risk gaining weight again. It is recommended to taper the medication slowly over time. Talk with your medical provider about gradually reducing your dose before you stop your medication.

The use of weight loss medications, particularly the drugs discussed in this article, continues to rise within the United States. Obtaining insurance coverage for these medications is becoming increasingly more difficult. If you’re considering starting one of these medications, review your insurance policy to learn more about your coverage options. Some insurance plans may cover one or all agents, while some may not cover them at all. Speak with your medical provider about the best medication for your health condition.