Weight Loss Shots Covered By Insurance – Complete Guide

Trying to lose weight can be really tough and expensive. But, new medications like Wegovy and Zepbound might change that. They help people lose weight and keep it off¹.

These shots cost between $1,000 to $1,500 each month¹. Many people and companies wonder if insurance will cover them. This guide will help you understand if your insurance will pay for these shots. We’ll look at the rules and what might stop you from getting them.

• GLP-1 weight loss drugs like Wegovy and Zepbound can cost $1,000 to $1,500 per month.
• 76% of companies cover GLP-1 drugs for diabetes, but only 27% cover them for weight loss.
• Medicare typically does not cover weight-loss medications, except for patients with Type 2 diabetes.
• Medicaid coverage for weight-loss drugs varies by state, with only a few including them in their EHB benchmark plans.
• Employers are concerned about the long-term costs and benefits of covering these weight-loss shots.

GLP-1 receptor agonists, like semaglutide and tirzepatide, are popular for weight loss and treating type 2 diabetes². But, getting insurance for these FDA-approved injections can be tricky. You often need a type 2 diabetes diagnosis to get approved².

The FDA has approved Wegovy, Saxenda, and Zepbound for weight management². Insurance might only cover these drugs if you have an obesity-related condition, not just being overweight².

GLP-1 medications reduce hunger and slow digestion, helping you lose weight³. Orlistat (Xenical and Alli) stops fat absorption in your gut³.

GLP-1 drugs for diabetes include Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza, and Saxenda³. They might be used off-label for weight loss. But, getting insurance for diabetes treatment is easier than for weight loss³.

“GLP-1 medications have experienced growing popularity over the last several years for both treating type 2 diabetes and long-term weight management.”³

GLP-1 drugs are usually safe but can cause side effects like nausea and diarrhea³. There have also been shortages, making them harder to get³.

To lose weight, you need medication, a healthy diet, and more exercise³²⁴.

In the United States, the coverage for weight loss medications varies a lot⁵. Medicaid has seen a big jump in GLP-1 prescriptions and spending in recent years. About 40% of adults and 26% of children with obesity are covered by Medicaid⁵. But, most state Medicaid programs don’t cover GLP-1 medications for obesity treatment⁵.

The Affordable Care Act (ACA) Marketplace plans rarely cover drugs for obesity treatment⁵. Only 1% of Marketplace plans cover Wegovy, while 82% cover Ozempic⁵. Most plans use tools like prior authorization and quantity limits to manage these medications⁵.

Employer-sponsored health plans have more freedom in their coverage choices. But, only about 25% of these plans cover GLP-1 drugs for weight loss⁵. This lack of coverage makes it hard for people to get these effective treatments⁶.

The cost of weight loss medications, like Ozempic, can be very high, from $900 to over $1,000 per month without insurance⁶. This, along with limited coverage, makes it hard for people to get these treatments⁶. Advocates suggest working with healthcare providers to find cheaper options and pushing for better coverage from insurers and employers⁶.

The insurance landscape for weight loss shots is still fragmented. Medicaid, ACA Marketplace plans, and employer-sponsored health plans offer different levels of coverage⁵. As more people seek effective weight management solutions, it’s crucial for policymakers, insurers, and healthcare providers to work together. They must ensure more widespread and affordable access to these life-changing treatments⁵.

The world of insurance for weight loss shots is changing fast. There are big differences in what commercial plans, Medicare, and Medicaid cover. Even though some progress has been made, it’s still hard to get these treatments for everyone.

About 50 million adult Americans have insurance for weight loss medicines. But, not all insurers want to cover it. Blue Cross Blue Shield of Michigan stopped covering three weight loss drugs: semaglutide, tirzepatide, and liraglutide⁷.

This change affects nearly 10,000 members who were using these drugs⁷. Those without insurance might have to pay up to $1350 a month for drugs like semaglutide⁷.

Medicare doesn’t usually cover weight-loss medicines, except for those used to treat other health issues⁸. But, if Medicare did cover these medicines, it would cost the federal government about $35 billion from 2026 to 2034⁸. Medicaid’s coverage for weight loss shots varies by state. Some states, like North Carolina and New Mexico, cover these medicines in their Essential Health Benefits plans⁷.

State decisions add more complexity to weight loss shot coverage. North Carolina’s State Health Plan spent $100 million on GLP-1s for weight loss in 2023. They expect to lose $1.5 billion by 2030⁷. North Dakota will start covering weight loss medicines in 2025⁷.

Other healthcare systems, like RWJBarnabas Health and Mayo Clinic, have also made decisions on covering these medicines⁷.

The current state of insurance for weight loss shots shows we need a better plan. We must make sure these treatments are available to those who need them. As obesity costs keep going up⁸, it’s key for policymakers, insurers, and healthcare providers to work together on this issue.

The cost of GLP-1 weight loss medications is a big deal⁹. In the U.S., a monthly supply can cost between $936 for Ozempic and $1,349 for Wegovy⁹. But, how much you pay can change a lot based on your insurance and other things.

Without insurance, GLP-1 drugs can cost up to $18,000 a year for each employee⁹. But, if you have big employer coverage, you might pay about $70 a month for semaglutide⁹. The makers of these drugs offer savings programs that can cut your cost by up to 50%⁹.

How much people are willing to pay for these injections changes a lot based on their income¹⁰. Over $250,000 a year, almost 60% are okay with paying more than $300 a month. But, only about 4% of those making less than $75,000 are willing to pay more than $50 a month¹⁰. This shows how important insurance and financial help are for making these treatments fair for everyone.

Insurance plays a huge role in how much GLP-1 weight loss medications cost⁹. The U.S. has a high obesity rate, but Medicare doesn’t cover these drugs⁹. Medicaid coverage also varies by state⁹. This makes it harder for people with lower incomes to get these treatments.

“About half of U.S. adults would be interested in taking prescription weight-loss drugs, although interest decreases if insurance coverage is absent or if potential weight regain after stopping the medication is mentioned.”⁹

The obesity epidemic affects millions in the U.S. Employer health plans’ coverage of weight loss meds, like GLP-1 injections, is key¹¹. Obesity impacts 42% of adults, yet insurance for these treatments varies widely.

Health plans vary by employer. Self-insured plans have more freedom, while fully-insured plans follow state rules¹². Only about 30% of employers cover GLP-1s for weight loss¹². But, 76% do for diabetes.

Even with coverage, there are big limits and rules¹¹. Most plans need prior approval for GLP-1s for weight loss¹¹. They also set limits on how much you can get¹¹.

Some plans require trying other treatments first¹¹. But, this is rare, affecting less than a quarter of plans¹¹.

More research on GLP-1s could change coverage¹². Studies on their use for kidney disease and sleep apnea might influence decisions¹². Yet, some companies stop covering weight loss drugs, and rules can change yearly¹².

The need for weight loss solutions is growing. The relationship between employer plans, coverage, and future trends will shape access to these treatments¹¹¹².

Insurance coverage for weight loss drugs depends on several factors. You need to meet specific body mass index (BMI) thresholds and have an obesity diagnosis. Patients often need to have a BMI over a certain¹³ or an official obesity diagnosis to qualify¹³.

Insurance plans might also require you to join lifestyle modification programs before approving weight loss medications. This could mean showing you’ve done nutrition counseling, exercise, or other weight management activities¹⁴.

Another challenge is the step therapy requirement. You must try cheaper medications or treatments first before getting more expensive weight loss drugs¹⁴. This can make it harder for those seeking full coverage for their weight management needs.

Coverage for weight loss medications, especially GLP-1 drugs, is more common when they’re used for diabetes or cardiovascular disease rather than just for weight loss¹⁴. Knowing your insurance plan’s specific criteria is key to understanding weight loss medication coverage.

Getting insurance for weight loss meds can be tough. Many plans need prior authorization and step therapy to control costs and ensure proper use. Prior authorization means you must send in detailed info like BMI, obesity diagnosis, and weight loss program proof¹⁵.

To get weight loss injections covered, you might need to send in several documents. These include medical records showing a BMI of 35 or higher, obesity diagnosis, and weight loss program participation for at least six months¹⁵. Some plans also ask for digital weight management program enrollment, like Teladoc Health¹⁵.

• Specific eligibility requirements, such as age or BMI thresholds¹⁵
• Annual and lifetime maximums on the number of doses or duration of treatment¹⁵
• Restrictions on the use of weight loss medications in combination with other weight loss products or by individuals with type 2 diabetes¹⁵

These limits aim to make sure weight loss meds are used wisely and cost-effectively. But, they can also make it hard for patients to get these treatments¹⁵. Knowing your insurance plan’s specific needs is key when thinking about weight loss injections¹⁶.

The process to get weight loss meds approved can be complicated. Insurers often prefer cheaper options or question the need for newer, pricier drugs like Zepbound (tirzepatide)¹⁶. But, there are ways to appeal, like manufacturer help programs or looking into other coverage options¹⁶.

Getting weight loss injections can be expensive, but there’s good news. Pharmaceutical companies offer pharmaceutical assistance programs, drug discount programs, and savings cards. These help patients save money¹⁷. You can get discounts of up to 50% or even $500 off each month¹⁸.

Big names like Novo Nordisk and Eli Lilly have special programs. They help patients who don’t have insurance. To get these deals, check the websites of these companies¹⁸. As more companies enter the market, we might see even better deals¹⁸.

Using these pharmaceutical assistance programs, drug discount programs, and savings cards can really help. They make weight loss injections more affordable. This way, patients can focus on their health goals without worrying about money¹⁸.

“Accessing affordable weight loss medications is crucial for patients seeking effective treatment options. Manufacturer assistance programs can make a real difference in making these therapies accessible.”

Getting weight loss meds like Ozempic and Wegovy can be tough due to insurance issues. But, there are other ways and plans to make these treatments easier to get¹⁹.

Health Savings Accounts (HSAs) are great for covering weight loss meds. You can use pre-tax dollars for medical costs, including some weight loss drugs²⁰. Check with your plan to see if your meds qualify for HSA coverage²⁰.

Flexible Spending Accounts (FSAs) work like HSAs for weight loss meds. You can set aside pre-tax income for medical costs, including some weight loss drugs²⁰. Make sure to talk to your plan to know what’s covered and what’s not²⁰.

Looking into HSAs and FSAs can help lower the cost of weight loss meds. This makes these treatments more affordable and accessible²⁰.

“Flexible spending accounts (FSAs) allow contributions up to $3,050 annually for health expenses, while health spending accounts (HSAs) permit up to $3,850 (for individual coverage). Unused FSA funds may be forfeited at year-end, while HSA funds can be carried over.”²⁰

The world of insurance for weight loss treatments is changing fast. North Carolina’s State Employee Health Plan stopped covering GLP-1 agonists for non-diabetic members because of high costs²¹. Louisiana is now looking into adding obesity treatments, including FDA-approved drugs, to their Essential Health Benefits package².

Other states are also making moves. Colorado almost passed a law to cover FDA-approved obesity meds, but it didn’t make it². The Department of Health and Human Services is thinking about changing the rules for what insurance plans must cover. This could affect the availability of weight loss drugs².

These changes show the ongoing debate about covering GLP-1 weight loss meds and other obesity treatments²¹²²². With more people becoming obese, there’s a big push to find ways to help manage weight. But, there’s also a need to keep costs down.

It’s key for people to know what their insurance covers and to talk to their doctors about getting weight loss meds²²². As the industry keeps changing, it’s important to stay informed about insurance policy updates. This will help those looking for effective ways to manage their weight.

The world of weight loss drugs is changing fast. This is because more people want them and they might help with health. But, the cost is still a big problem. Patients need to know what their insurance covers and how much they might have to pay²³.

Changes in laws could affect who gets these drugs. More studies on how well they work and their cost will also play a part²⁴. It’s important for patients and groups to speak up as these changes happen.

Even though coverage is limited now, things might get better. More people talking about this and pushing for change could help. Laws like the Treat and Reduce Obesity Act of 2023 might make these drugs more available and affordable²³²⁴.

1. Most employer health plans don’t cover new blockbuster weight loss drugs, but that’s going to change – https://www.cnbc.com/2024/02/16/what-you-need-to-know-about-health-coverage-for-new-weight-loss-drugs.html
2. Does Insurance Cover Prescription Weight Loss Injectables?   – https://content.naic.org/article/does-insurance-cover-prescription-weight-loss-injectables
3. A Guide to Understanding and Navigating GLP-1 Coverage | NFP – https://www.nfp.com/insights/glp-1-coverage/
4. Does Insurance Cover Weight Loss Medication? – https://obesitymedicine.org/blog/does-insurance-cover-weight-loss-medication/
5. Medicaid Coverage of and Spending on GLP-1s | KFF – https://www.kff.org/medicaid/issue-brief/medicaid-coverage-of-and-spending-on-glp-1s/
6. Ozempic: Insurance Providers Are Ending Coverage of Weight Loss Drugs – https://www.healthline.com/health-news/insurance-providers-are-halting-coverage-of-ozempic-and-other-glp-1-drugs
7. Rising Costs Lead Insurers to Drop Weight Loss Drug Coverage, Further Increasing Patient Burden – https://www.ajmc.com/view/rising-costs-lead-insurers-to-drop-weight-loss-drug-coverage-further-increasing-patient-burden
8. Healthy Returns: Covering weight loss drugs could cost Medicare $35 billion through 2034 – https://www.cnbc.com/2024/10/15/healthy-returns-medicare-weight-loss-drug-coverage-could-cost-34-billion.html
9. How do prices of drugs for weight loss in the U.S. compare to peer nations’ prices? – Peterson-KFF Health System Tracker – https://www.healthsystemtracker.org/brief/prices-of-drugs-for-weight-loss-in-the-us-and-peer-nations/
10. Here’s how much people are willing to spend on weight loss drugs, according to a new survey – https://www.cnbc.com/2024/03/23/weight-loss-drug-cost-how-much-people-are-willing-to-spend.html
11. Insurer strategies to control costs associated with weight loss drugs – Peterson-KFF Health System Tracker – https://www.healthsystemtracker.org/brief/insurer-strategies-to-control-costs-associated-with-weight-loss-drugs/
12. Does Workplace-Sponsored Insurance Cover Anti-Obesity Medications? – https://www.verywellhealth.com/does-workplace-sponsored-insurance-cover-anti-obesity-medications-8648511
13. How to get Wegovy covered by insurance – https://www.singlecare.com/blog/how-to-get-wegovy-covered-by-insurance/
14. Here’s what it would take for insurance to cover weight loss drugs – https://www.nbcnews.com/health/health-news/insurance-cover-weight-loss-drugs-take-rcna120091
15. Changes coming for select weight loss drugs for some commercial members – https://www.bcbsm.com/content/dam/microsites/corpcomm/provider/the_record/2024/jul/Record_0724h.html
16. How To Get Prior Authorization For Zepbound — A Guide – https://www.helloklarity.com/post/prior-authorization-for-zepbound/
17. Obesity Prescription Savings Card Offers for Patients | novoMEDLINK™ – https://www.novomedlink.com/obesity/patient-support/savings-coverage/savings-card.html
18. Wegovy cost 2024: Coupons, savings, and more – https://www.medicalnewstoday.com/articles/drugs-wegovy-cost
19. Ways to Gain Coverage for Wegovy™ | Wegovy™ (semaglutide) Injection 2.4 mg – https://www.wegovy.com/coverage-and-savings/wegovy-coverage-options.html
20. How to Continue Taking Mounjaro or Ozempic When You Can’t Afford It – https://www.verywellhealth.com/how-to-afford-mounjaro-or-ozempic-7547704
21. Medicare plans can now cover the weight-loss drug Wegovy – https://www.npr.org/2024/03/22/1240304847/medicare-plans-can-now-cover-the-weight-loss-drug-wegovy
22. Costs and Insurance Coverage for Ozempic, Wegovy & Weight Loss Drugs – https://www.valuepenguin.com/weight-loss-drug-cost-health-insurance
23. The push for Medicare to cover weight-loss drugs: An explainer – https://journalistsresource.org/home/semaglutide-ozempic-wegovy-weight-loss-drugs-research/
24. GLP-1 Drugs for Weight Loss: What Employers Need to Know – https://www.vitacompanies.com/blogs/the-vita-blog/GLP1-Drugs-for-Weight-Loss-What-Employers-Need-to-Know/