Key tips for insurance coverage of weight loss drugs

New drugs such as Ozempic and Wegovy can both be used to lose weight, but they're expensive and commercial insurers typically don't cover the cost, though there are options to potentially receive coverage.

GLP-1 drugs, including Ozempic, Trulicity, Victoza and Mounjaro, are used to treat Type 2 diabetes, while Wegovy and Saxenda are approved for weight loss. Though the active ingredient in Ozempic and Wegovy is the same, payers typically only cover drugs meant for treating diabetes, not those prescribed to lose weight.

In first quarter earnings calls, the nation's largest insurers said they have mostly constrained coverage of GLP-1s to treating diabetes. 

"We need to really be clear about which patients really do benefit from these medicines and make sure we properly understand how they're going to use those medicines," UnitedHealth Group CEO Andrew Witty told investors in April. "There's a lot still to learn as these things progress through their final phases. We've got to see the prices be affordable, and that's going to be a key element of how this evolves."

According to The Wall Street Journal, these are two key ways experts recommend seeking coverage for GLP-1 drugs for weight loss:

Speak with a physician: patients should first understand if a GLP-1 drug is best for their condition. Obesity specialists may be more knowledgeable with navigating insurance coverage.

Speak with the health plan: Most health plans won't offer coverage, but it's worth checking. Some insurers may only cover certain GLP-1 brands, and not others. Some health plans require evidence that weight loss strategies such as exercise or diet changes have not worked previously, while other plans may require a coinciding behavioral weight-loss program if coverage is provided.

If patients are able to secure coverage for weight loss, their out-of-pocket costs could still be significant, according to the WSJ. Most drug manufacturers do offer assistance programs to help pay those costs.

In addition, securing coverage once does not guarantee permanent coverage. Some health plans may require weight loss milestones to continue coverage, while others may terminate coverage if the patient successfully loses enough weight. 

For Medicare enrollees, weight loss drugs are never covered. In 10 states, Medicaid offers broad coverage for weight loss drugs, according to Bloomberg. 

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