Will your health insurance cover weight-loss medications? It depends on several factors, including where you live
May 08 2024 - 11:23AM
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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