If you’ve watched TV or spent any time online lately, you’ve likely seen ads for weight loss drugs. They often highlight the dual benefits of not only shedding pounds but also managing diabetes. The results are undeniable, but there’s one major catch: these drugs come with a steep price tag. And if you’ve tried to get your insurance to cover them, you may have run into some frustrating roadblocks.

Up to now, insurers have been reluctant to prescribe them!

And in today’s blog, we will discuss the best ways to get your health plan to pay for your prescription and even methods you could use to lower the fees of your medications. 

Back in the years, weight loss drugs have sometimes been considered a “lifestyle” or “cosmetic” issue. However, the World Health Organization (WHO) recognizes obesity as a chronic disease. This classification highlights that obesity is a long-term, relapsing condition that requires ongoing management, rather than just being a result of lifestyle choices or temporary weight gain. 

Weight Loss Medication 

Before we get to the ways to get your health plan to pay for your prescription, we need to understand what weight loss medication we are referring to and who are they geared towards.

The category of medication we are talking about are GLP and GLP-1 agonists medication. You may have heard of Semaglutide and Tirzepatide, these are weight loss medications that work by mimicking the effects of a naturally occurring gut hormone. 

In short, these are FDA-approved medications that contribute to weight loss up to 15 to 20 percent loss of body weight and both Semaglutide and Tirzepatide are both geared toward people with type 2 diabetes. 

You can find more details about Semaglutide and Tirzepatide if you are interested in our website: https://naturopathicweightloss.com/blog/ 

What you should know

It’s true that many employers and insurance plans don’t cover medications specifically for weight loss. You might wonder, though, if having a prescription from a doctor is enough for an insurer to cover the cost?

Well, not necessarily, it is not often the only green light.

If your doctor prescribes one of these drugs, there’s usually a process to follow. Often, your doctor will need to get prior authorization from the insurance company to cover the medication. This might involve filling out a form or writing a letter.

The insurance plan typically wants to proof that you really need the drug. For example, if you have type 2 diabetes and need GLP-1 medication, you might need to show that you have diabetes and that you’ve tried other diabetes medications without success. They might also check if you meet specific criteria, like having a BMI of 30 or higher, or 27 or higher with a related health condition like high blood pressure. Additionally, they sometimes want to see that you’ve tried other weight loss methods, such as a structured program.

Now, if your health plan covers GLP or GLP-1 medication, does that mean you’re off the hook for any out-of-pocket costs?

It depends on your health plan. Anyone who has had different health plans knows that out-of-pocket costs can vary widely for the same treatment, depending on your employer or insurance provider. Sometimes, you might just have a flat co-pay like you do for many medications, but since these drugs are expensive, employers are cautious about the costs—both for individual patients and the number of people who might need them.

Other options?

So, if you’ve found out that your employer and insurance don’t cover your medication, does that mean you’re out of luck and won’t get the treatment you need? 

Not at all! 

There are plenty of rebates and discounts offered by manufacturers that can significantly lower the cost of these drugs—sometimes by over 50%.

Other alternatives are prescription rate. “If you have diabetes and you can prove it, you can easily register for a prescription rate and receive discounts

There are also other methods knowns as co-pay and co-insurance. 

You may not be aware but your insurance plan might offer different ways to share the cost. Instead of having you pay the full price out-of-pocket, your plan could require a co-pay, which is a fixed amount you pay each time you fill the prescription. For example, you might pay a consistent $20 per refill, regardless of the medication’s actual cost. 

Alternatively, your plan might involve co-insurance, where you pay a percentage of the medication’s price, such as 20%. This means if semaglutide costs $200, you would pay only $40. 

It is understandable that all the methods mentioned can become overwhelming as it may involves contacting your insurance, your doctor and filling documents back and forth. 

There are people who prefer turning to “Buy Now, Pay Later” (BNPL) options to help spread out these costs, making it easier to manage.

With BNPL, you can break down the price of your medication into smaller, more affordable payments over time. For example, instead of paying $400 upfront for a month’s supply of semaglutide, you might pay $100 every two weeks for two months. This way, you get the medication you need right away, without straining your budget. Many companies offer these kinds of services, and they often don’t charge interest if you make your payments on time.

Conclusion 

Now the good news: these medications are already approved for treating diabetes and reducing cardiovascular risk, and there are more studies coming out soon that could lead to approvals for other conditions common in people who are obese, like chronic knee pain, osteoarthritis, and sleep apnea. If these new uses get approved, they could end up being covered by insurances. 

Finger crossed but it seems that over the next few years, we’re likely to see more of these medications being approved and becoming more accessible through healthcare, even if congress doesn’t act right away. So, it’s a good bet that coverage will expand, and more people will be able to access these treatments.