If you are considering taking injectable anti-obesity medication such as Wegovy or Zepbound, you will also have to consider the cost.
The medications, which belong to a class of drugs called glucagon-like peptide (GLP-1) receptor agonists, have list prices of over $1,000 per month. While people with health insurance through their employer or the Affordable Care Act (ACA) typically have coverage for medications, fewer than 30% of employers currently cover GLP-1s indicated for weight loss, according to a fall 2023 survey by the International Foundation of Employee Benefit Plans. When similar medications, like Ozempic and Mounjaro, are prescribed for diabetes, the likelihood of coverage increases to 76%.
ACA health insurance plans are not required to cover anti-obesity medication.
Rick Kelly, National Practice Leader at professional services firm Marsh McLennan, told Verywell more employers used to cover anti-obesity medication and related diabetes medications, but the popularity of GLP-1s has prompted them to pump the brakes.
“A couple of years ago, that number was much higher,” Kelly said. “It was probably around 70% to 75% [of employers] before people really understood the financial exposure of covering those drugs.”
Employer Coverage Can Get Complicated
Moving forward, companies that agree to offer insurance coverage for GLP-1s may require employees to complete several steps.
“The question is going to be what processes, what prior authorizations, what utilization management programs will be in place,” Kelly said.
For instance, rather than just charging a copay, a workplace insurance plan may introduce its own prerequisites for a BMI threshold, mandate a patient try other medications, diet, or exercise plans first, and/or require a letter from a physician confirming the patient meets the company’s criteria for drug coverage.
Appealing an insurer’s decision to deny coverage is possible. But Kelly said that, in 2024, you’re not likely to have much success. Appeals allow insurers and employers to learn about treatments they might not have been aware of.
“There are very few employers in the country who don’t know about these drugs at this point,” Kelly said. “They have probably already been approached by employees if they’re not covering this drug.”
How to Continue Taking Mounjaro or Ozempic When You Can’t Afford It
Will Insurance Coverage For Anti-Obesity Medications Improve?
There are some potential bright spots when it comes to coverage of GLP-1s, but likely not during 2024. For example, while Medicare does not cover weight loss drugs at all—by law, they are not permitted to—pending legislation called the Treat and Reduce Obesity Act could change that. It will probably take several years to take effect, Juliette Cubanski, deputy director of the Program on Medicare Policy at health research firm KFF, told Verywell.
More immediately, new uses of medications initially intended for obesity could prompt coverage for those indications. For example, the Food and Drug Administration (FDA) recently added an indication to Wegovy for the prevention of cardiovascular events in people who have obesity or overweight and have heart disease. Insurers, including Medicare, are now covering that use.
There are ongoing clinical trials studying the use of GLP-1 drugs for a range of conditions beyond obesity, including kidney disease and sleep apnea. FDA approvals of those uses could prompt insurers to cover the drugs for those indications.
“Going forward, it may be harder and harder not to cover them as we see indications expand,” Andrea Ducas, vice president for health policy at the Center for American Progress in Washington, D.C., told Verywell. “But the prices could also drop as new weight loss drugs enter the market, and one or more become subject to Medicare price negotiation, which, if successful, would put downward pressure on the price of the drugs for other payers.”
What This Means For You
Companies that previously covered the drugs in years past for weight management may no longer do so. Make sure you check the fine print of your employer-sponsored health plan each year during enrollment, since drug coverage and coverage requirements can change every year.
Whether workplace-sponsored insurance covers anti-obesity medications can vary significantly depending on the specific insurance plan and the employer.
Coverage Variability
Employer-Sponsored Plans:
- Fewer employers are covering anti-obesity medications than in previous years. A 2023 survey found that fewer than 30% of employers cover GLP-1 medications like Wegovy and Ozempic for weight loss. However, when these medications are prescribed for diabetes, coverage rates increase significantly, up to 76%.
Affordable Care Act (ACA) Plans:
- Insurance plans under the ACA are not required to cover anti-obesity medications. This means coverage can be inconsistent and often subject to high copays or strict pre-authorization requirements.
Coverage Conditions
Additional Requirements:
- Some plans may require patients to try less expensive medications or participate in diet and exercise programs before approving coverage for GLP-1 medications. Additionally, there may be specific BMI thresholds and other criteria that need to be met.
New FDA Indications:
- The recent FDA approval of Wegovy for reducing cardiovascular risks in patients with obesity may lead some insurers to cover the medication for this use, even if they do not cover it strictly for weight loss.
Medicaid and Medicare
Medicaid:
- Medicaid coverage for anti-obesity medications varies by state. Only 16 states currently list GLP-1 medications for weight management on their covered drug lists, and even in those states, obtaining coverage can involve meeting stringent requirements.
Medicare:
- Medicare generally does not cover weight loss medications due to legislative restrictions, but it may cover these drugs if they are prescribed for other FDA-approved uses, such as managing diabetes or reducing cardiovascular risk.
Future Prospects
Legislative Changes:
- Ongoing legislative efforts, such as the Treat and Reduce Obesity Act, aim to expand coverage for anti-obesity medications under Medicare and could influence future coverage trends for employer-sponsored insurance as well.
In summary, while some workplace-sponsored insurance plans and Medicaid programs do cover anti-obesity medications, coverage is far from universal and often comes with specific conditions and limitations. It is important to review your specific insurance policy and consult with your provider to understand your coverage options.