Will Your Insurance Approve You for Weight Loss Medication? Here’s How to Find Out.
In the United States, over 50% of Americans medically qualify to receive life-changing weight loss medications, but unfortunately, only 2% receive them. Telehealth practices like our Weight Biology Reset program are working to make these medications more accessible. Still, even if you get a doctor to prescribe you the most effective drug, the cost barrier can be a massive problem for most people.
The most effective of the FDA-approved medication for weight loss, WeGovy, can cost up to $1500/month, and the most effective off-label medication, Mounjaro, is also upwards of $1,000/month. This price range is not doable for most people, which is one reason why injectable GLP-1s have gotten the reputation of being the “weight loss drug for the rich and famous.”
But don’t throw in the towel just yet. Insurance coverage for these medications is completely possible! Here’s how to find out if your insurance company will cover the cost of your weight loss medication.
Do You Qualify for Weight Loss Medication?
Before pursuing weight loss medication, it’s helpful to understand the guidelines that doctors use to write these prescriptions.
Your initial eligibility for weight loss medication depends on your current weight, in addition to any other health conditions. According to the FDA, doctors can write weight loss prescriptions for patients who:
- Have a body mass index (BMI) of 30 or greater
- Have a body mass index (BMI) of >27 in addition to an underlying metabolic health condition
Based on these parameters, you may not immediately qualify for weight loss medication, but you can still get an evaluation from a board-certified obesity medicine doctor to see if you have an underlying metabolic condition that needs treatment. Medication is never guaranteed—it’s prescribed on a case-by-case basis—but the right doctor will equip you with the right medication and/or lifestyle changes to help you reach your health goals.
If your doctor finds you a good fit for weight loss medication, they may choose to write you an FDA-approved weight loss prescription, but they also can write prescriptions off-label. Many drugs shown to be extremely effective for weight loss are not currently FDA-approved for this use, but that doesn’t mean they won’t help you. Examples of common drugs prescribed for off-label use include Metformin, Ozempic, and Mounjaro, which are approved for Type 2 diabetes, but also work to help many people lose weight.
If your doctor writes you an off-label medication, there’s likely an underlying metabolic reason why they believe this medication will work well for you, but your insurance company may need prior authorization from your doctor. If a certain medication is covered by your plan, and your doctor determines that you need it, off-label medications can still be covered by your plan.
As we mentioned, these prescriptions can be expensive without insurance. To help your doctor write you the best prescription for your body—and your budget—here’s what to ask your insurance company before your doctor appointment.
How to Get Your Medication Approved
To get the best medication for you covered by your insurance, be prepared before your first appointment with your doctor.
Understand Your Deductible
A medical deductible is the amount of money you are responsible for paying before your health insurance starts paying for your medical expenses.
For example, if your health insurance plan has a $1,000 deductible, you must pay the first $1,000 of your medical expenses out of your pocket before your insurance company starts to cover any costs for the year. Once you’ve met your deductible, your insurance plan will typically cover a percentage of your medical expenses through year-end, with the remainder being your responsibility to pay.
It’s important to note that not all medical expenses count toward your deductible. Some health insurance plans have separate deductibles for medical services and prescription medications. Even if you have already met your deductible for medical services, you may still have to pay the full cost of your medications until you reach your prescription drug deductible. It’s always a good idea to review your insurance plan documents and contact your insurance company directly to understand which medical expenses count towards your deductible and which don’t.
Long story short, even if your prescription is considered covered by your plan, you will still have to pay the entire amount of the cost of the prescription until you reach your deductible!
Ask Your Insurance About Specific Medications
You can save yourself a lot of struggle, time, and money by asking your insurance company in advance about their coverage of weight loss medications.
In order to find out if weight loss medication is covered under your specific plan, contact your insurance company’s customer service department and ask if weight loss medication is listed as a covered benefit in your plan. Be sure to have your policy number and any other relevant information handy!
If you have a specific weight loss medication in mind, ask your insurance company if it is covered under your policy. You may also want to ask if there are any restrictions or requirements for coverage, such as a doctor’s pre-authorization or a history of unsuccessful weight loss attempts. Here’s a list of common weight loss medications you can ask about:
While you’re on the phone, it’s also a good idea to clarify what you’re responsible for when it comes to prescription copays or coinsurance. Ask about how these costs associated with weight loss medication apply to your specific policy!
If you receive information over the phone, follow up in writing to confirm what you were told. This can help ensure that you have a record of your conversation and any information provided.
Talk to Your Doctor
When you come to your appointment to discuss weight loss medication with your doctor, share everything you learned about your insurance coverage and any concerns about the cost of medication so they can help write you the best prescription for you.
Once your doctor has the full picture of both your health and your insurance coverage, they’ll be more equipped to work with you to prescribe a medication that works for your budget and goals.
Even if your prep work with the insurance company made it seem impossible to get your medication covered, depending on any other conditions, like metabolic dysfunction or PCOS, your doctor may be able to appeal to your insurance company for coverage. So don’t give up until after your doctor has tried to get your medication prescribed!
What If Insurance Won’t Cover It?
In the worst-case scenario of your insurance company not covering your medication or having a high deductible, there are avenues for more affordable medication coverage.
Your doctor may choose to write you a prescription for a more affordable prescription like Metformin, or you can find coupons from GoodRX or directly from the drug manufacturers. Unfortunately for prescriptions like WeGovy and Ozempic, the cost will usually still be $700+.
If you simply cannot afford weight loss medication, the right supplements and food changes for your biology can also help you unlock your weight loss and health goals. Switching to a way of eating that doesn’t spike your blood sugar unnecessarily can also help you avoid cravings, which is a major benefit of weight loss medication.
The best way to ensure your success, medication or not, is to work with a doctor who understands the science behind effective weight loss. The doctors in SoWell’s Weight Biology Reset see a 90% success rate with their patients and will work with you to create the best plan to help you lose weight based on your specific biology and lifestyle. Learn more about the program here.