Does Insurance Cover Weight Loss Medication Like Ozempic?
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Medications prescribed for the purpose of treating obesity are rarely covered by Affordable Care Act (ACA) Marketplace plans or Medicaid and are never covered by Medicare. Even Ozempic, which can be prescribed to help you lose weight, is usually only covered if it is prescribed to treat diabetes instead. Nevertheless, health plans generally cover nutrition counseling and services aimed at preventing obesity and may also cover weight loss surgeries.
Read below for an overview of the obesity treatments your health plan is most likely to cover and how you can get weight loss drugs covered by insurance.
Are Weight Loss Drugs Covered by Insurance?
ACA-compliant health insurance plans are not required to cover weight loss medications, so the majority of them do not. A 2017 study that analyzed 136 Marketplace plans from 34 states found that only 11% of the plans included some coverage for weight loss drugs, with plans from 25 of those states having no such coverage.
These limitations are not exclusive to private health insurance plans but also apply to government-funded healthcare programs. Of the 34 states analyzed in the aforementioned 2017 study, only seven of their Medicaid programs offered some weight loss drug coverage. Meanwhile, Medicare Part D explicitly excludes coverage for prescription weight loss drugs.
However, Ozempic has only been approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes. As a result, insurers will typically only cover Ozempic if it is prescribed for diabetes treatment rather than weight management.
How Do I Know if I Qualify for Weight Loss Medication?
A doctor may prescribe you a weight loss drug if you have been unable to lose weight through diet and exercise alone and have a body mass index (BMI) over 30. You may also qualify with a BMI between 27 and 30 if you have an underlying health problem like diabetes or high blood pressure.
What Weight Loss Treatments Do Insurance Companies Cover?
Even if your health insurance doesn’t cover weight loss drugs, it may cover all or part of the costs for other services that can help you prevent or treat obesity.
Marketplace health plans are required to cover preventive obesity screenings as well as type 2 diabetes screenings for adults ages 40 to 70 who are overweight or obese. Your insurance company must pay 100% of the costs for these preventive services, meaning you won’t pay anything out of pocket even if you haven’t yet met your deductible for the year.
Similarly, Medicare Part B covers obesity screenings for Medicare members who have a BMI of at least 30. These screenings come with no out-of-pocket costs as long as your doctor accepts Medicare and agrees to the Medicare-approved payment amount for the service. Medicaid and the Children’s Health Insurance Program (CHIP) may also cover BMI screenings, although the exact benefits offered by these programs vary from state to state.
Nutritional Therapy and Counseling
Health insurance coverage for nutritional therapy and counseling is generally similar to coverage for preventive screenings. For example, ACA health plans cover all of the costs for obesity counseling plus diet counseling for adults who have a high risk of chronic disease.
Meanwhile, Medicare Part B completely covers behavioral therapy sessions that include a dietary assessment and counseling focused on improving diet and exercise. However, these sessions are only covered for Medicare members with a BMI over 30 who receive counseling from their primary care physician in a primary care setting such as a doctor’s office.
In addition, coverage you receive through Medicaid or CHIP may help take care of the costs of receiving education and counseling on topics such as nutrition and physical activity depending on the state you live in.
Weight Loss Surgery
ACA health plans are not universally required to cover weight loss surgeries. That said, 23 states include bariatric surgery among the minimum essential benefits that all Marketplace plans in that state must cover. In some cases, your insurance carrier may set certain eligibility requirements for bariatric surgeries, meaning they may only be covered if you:
- Are more than 18 years old
- Have a BMI above 40 or have a BMI between 35 and 40 plus high blood pressure, type 2 diabetes or a similar comorbidity
- Can prove that you have attempted to lose weight for an extended period of time
- Participate in a weight loss program as directed by your insurer
- Undergo a psychological examination
- Quit smoking before your surgery
- Don’t have a history of substance abuse
- Were diagnosed with morbid obesity a specified amount of time before your surgery
Medicare provides coverage for some types of weight loss procedures such as gastric bypass surgery and laparoscopic banding surgery but only for beneficiaries who have previously undergone medical treatments for obesity that were unsuccessful and have a BMI of 35 or higher along with another medical condition related to obesity. Medicaid and CHIP may also cover bariatric surgeries when necessary depending on where you live.
What Should I Do if Insurance Won’t Cover Weight Loss Treatments?
If you receive notice that your health plan will not cover a certain weight loss treatment, you should reach out to your insurer to see if there are certain criteria you can meet in order to get the treatment covered. Alternatively, if you have insurance through your employer, you could ask your healthcare provider to send a letter to your employer explaining why you need a certain treatment and requesting for your health coverage to be extended to that treatment.
You could consider switching plans during open enrollment or, if applicable, a special enrollment period if you discover that your current plan will not cover a certain weight loss treatment under any circumstances. As you shop for a new plan, be sure to ask up front whether plans you are interested in cover weight loss surgeries or medications. If all else fails, your best options may be enrolling in a non-surgical medical weight loss program or using a resource like GoodRx to search for coupons for weight loss drugs.