Will your insurance cover weight-loss medications?
It depends.
Interest in medications prescribed for weight loss is skyrocketing, sparking consumer questions about whether health insurance covers these often expensive drugs. Today, medicareresources.org explains that coverage depends largely on an individual’s health status, the type of coverage they have, and also where they live.
“Medical practitioners have seen a lot more interest lately in medications that promote weight loss, like Wegovy and Ozempic, and patients want to know if they’re covered and how much they’ll have to pay out-of-pocket,” said Dr. Tanya Feke, a health policy analyst for medicareresources.org. “These are FDA-approved medications, so there is some confusion for patients when they find out they may not be covered, especially by Medicare.”
HOW MEDICARE COVERS WEIGHT-LOSS MEDS:
Medicare Part D prescription drug coverage will only cover medications that are prescribed for the treatment of specific medical conditions, such as diabetes or cardiovascular disease. It will not cover the medications, which are also known as GLP-1 agonists, for weight loss alone.
These GLP-1 receptor agonists are covered by Medicare when they are prescribed to treat Type 2 diabetes: Mounjaro, Ozempic, Trulicity, Rybelsus and Victoza. Wegovy, a medication with the same active ingredient as Ozempic and Rybelsus, is also now covered by Medicare if prescribed to reduce the risk of serious cardiovascular events in people who are known to have cardiovascular disease and are also overweight or obese – a new development that is fueling added interest in the coverage landscape for weight-loss drugs. Similar medications that are branded specifically for weight loss — Saxenda and Zepbound — are not covered at this time.
“The reason the medication is being prescribed is the No. 1 determinant of whether or not it will be covered by Medicare, and that reason can impact coverage under other types of plans as well,” explained Feke.
HOW OTHER INSURANCE COVERS WEIGHT-LOSS
MEDS: For consumers with coverage through an employer or through the Affordable Care Act (ACA) Marketplace, coverage of GLP-1 agonists will largely vary by state and by plan.
“Consumers shouldn’t assume their health insurance covers weightloss medications. Several factors impact whether a weight-loss medication will be covered,” said Louise Norris, health policy analyst for healthinsurance.org. “You may have coverage for these medications because you’ve been diagnosed with diabetes or a cardiovascular risk, or because you live in a state like New Mexico, where Marketplace plans and some employer plans cover medications prescribed for weight loss alone.”
Here is how weight loss medications are currently covered:
MARKETPLACE COVERAGE:
ACA plans are not required at the federal level to cover weight-loss drugs. Each state sets its own coverage standards through their Essential Health Benefits (EHB) benchmark plan. Most current EHB benchmark plans do not include coverage for antiobesity medications, but some do, including New Mexico. New Mexico’s coverage was new as of the 2022 plan year, and the updated plan includes coverage of weight-loss programs, medications and surgery as part of “medically necessary treatment of morbid obesity and obesity.”
EMPLOYERSPONSORED COVERAGE:
The majority of employersponsored health plans in a 2023 survey covered GLP-1 agonists for the treatment of diabetes, but only about a quarter do so for weight loss. Coverage depends in part on whether the plan is self-insured or purchased by the employer in the large group or small group market. Small group plans are governed by the coverage standards each state sets through its EHB benchmark plan, but selfinsured plans and large group plans are not. Large group plans are subject to certain state mandates, while self-insured plans are not.