Will Insurance Approve Weight Loss Medication? 13 questions to find out what to do.

In the United States, over 50% of Americans medically qualify to receive life changing weight loss medications, but unfortunately, only 2% receive them.  

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 medications for weight loss, such as  Wegovy, Mounjaro and Zepbound can cost over $1000 per month. This price  range is not doable for most people, which is one reason why injectable GLP-1s  have gotten the reputation of being only for the Hollywood elite. 

How about you? Here’s how to find out if your insurance company will cover the  cost of your weight loss medication. 

1. 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 such as diabetes, high blood pressure,  high cholesterol, or sleep apnea.

2. Which medication does your doctor recommend?  

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 that are FDA approved for weight loss can be very expensive without  insurance and in some cases even with 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. 

3. Does your insurance cover weight loss 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. 

Contact your insurance company’s customer service department and ask if weight  loss medications are listed as a covered benefit in your plan. Be sure to have your  policy number and any other relevant information handy! If the answer is no,  your doctor can still prescribe the medication, but you will have to pay the full  price at the pharmacy. You can also write a letter to your employer benefits  coordinator (sample attached in files) to request coverage for weight loss  medications.  

4. Ask specifically which weight loss medications are covered by your  insurance?  

Let’s say the customer service representative of your insurance company says yes,  we cover weight loss medications. Do not accept this as the final answer because  it may mean nothing in your case. Ask your insurance company which weight loss  medications are covered under your policy. Here’s a list of common weight loss  medications you can ask about: 

• Zepbound 

• Wegovy 

• Saxenda 

• Ozempic 

• Contrave 

• Qsymia 

5. Are there any preferred weight loss medications?  

They may cover some medications without preauthorization, and it is important  to know which those are. In some cases, the preferred drugs are not an option for  you so you need to ask the next question. 

6. Is a doctor’s pre-authorization required for the specific medication?

7. Is there a need for documentation of prior “tried and failed”? 

They may want documentation for every weight loss medication on their  approved formulary that you used and why that is not an option at this time 

8. What are the insurance company specific criteria for the specific drug, and  which are those? 

For example, even if your BMI is 35, they may still require documentation that  you also have diabetes, or high blood pressure, or sleep apnea before they  approve Wegovy or Zepbound. 

9. Clarify what you are responsible for when it comes to prescription copays  and insurance. 

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!

10. Ask to receive a written statement of everything that was discussed over the  phone. 

This can help ensure that you have a record of your conversation and any  information provided. 

11. Ask your doctor what your next step is.  

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. 

• 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+. With copayment  card your cost for Zepbound will be around $500. 

• 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. 

12.Write a letter to your employer. 

If your insurance company does not cover weight loss medications, you can  contact your employer benefits representative and send them a letter to request  coverage ( letter sample below).

Sample letter you can write to your employer to request weight loss medication  coverage: 

(copy and paste and edit to reflect your personal situation) 

Name: 

Address: 

City, State and Zip: 

Phone Number with Area Code: 

Current Date: 

Benefits Manager’s Name 

Employer’s Title 

Employer’s Address 

Employer’s City, State, Zip 

Dear Benefits Manager, [INSERT NAME] 

In your first paragraph, mention the following points: 

1. Discuss how you recently contacted your insurance provider to inquire about  treatments for the disease of obesity and you were told that [INSERT  RECOMMENDED TREATMENT: bariatric surgery, FDA-approved anti-obesity  medications, nutritional counseling, mental health and behavioral counseling] is  not covered under their policy. 

2. Share a brief medical history of your struggles with this disease. Tell the  individual how obesity and its related conditions have affected you and your  family. Elaborate on the number and cost of medications you are currently taking  due to your obesity-related conditions. (Remember to remain brief. A short letter  can accomplish just as much as a long one.) 

In your second paragraph, mention the following items: 

1. The number of people affected by obesity (look up current state specific numbers) 

2. Health outcomes are better for all diseases when treatment options are 

available, affordable, and accessible. 

3. Patients with obesity deserve access to FDA-approved treatments in the same  way we cover treatments for hypertension, diabetes, and other chronic diseases. 

In your last paragraph, discuss the following closing items: 

1. Request that your employer adjust their insurance policy to include  comprehensive treatment for the disease of obesity including bariatric surgery,  FDA-approved anti-obesity medications, nutritional counseling, mental health and  behavioral counseling. 

2. Request a timely response and thank them for their time and assistance. 

Sincerely, 

Your Full Name