Getting insurance coverage for weight loss drugs like Wegovy®, Ozempic® and other GLP-1s

Healthcare can be expensive, especially without adequate insurance coverage. Insurance companies don’t always make it easy to navigate your plan or find out what’s covered. Even if something is covered, there can be fine print and other roadblocks that make the process even more difficult. Here’s an overview of what to look for in an insurance plan, how to navigate prior authorizations, and what fine print you may be looking over.

What are weight loss drugs? Glucagon-like peptide-1 (GLP-1) medications are used to treat health conditions such as obesity and type 2 diabetes. [1,2] GLP-1 drugs have been shown to improve cardiovascular risks, reduce weight, and lower blood pressure and cholesterol. [1-4] GLP-1s work by mimicking hormones in the body that regulate blood sugar, digestion, appetite, and more. Two well-known GLP-1 medications include Wegovy® and Ozempic®. [3,4]

The cost of weight loss medications can vary widely depending on your insurance plan or status. Without insurance, Ozempic® is estimated to cost around $900 a month and Wegovy® is estimated to cost around $1,350 a month. [5-6] If you do qualify for insurance coverage, the cost of GLP-1s can still vary widely from $0 to hundreds of dollars, although a general estimate for Ozempic® is about $25 for a monthly supply. [5-6] There are different payment assistance options for those that qualify that may bring the cost of these drugs down some more.

Unfortunately, there isn’t a one size fits all answer to this question. Medicare insurance plans do not cover weight loss drugs, while some Medicaid plans do cover GLP-1s. Some insurance plans will cover a few specific kinds of GLP-1s but not all. [7] It’s important to check your plan specifically to read over what medications are covered. In some cases, you may need a prior authorization to get a certain drug covered by your insurance.

A PA is approval from a health plan that may be required before you are able to get coverage for a specific service, treatment, or medication. [8] Your healthcare provider should be able to help you navigate PA requests.

If you are hoping to get any weight loss medications covered by your insurance, there are some things you need to keep in mind. Knowing how to read through your plan and what questions to ask your insurance provider and healthcare provider may help simplify the process.

First, you should double check your plan’s policies. Not all medications will be covered by your insurance plan, so you should have a list of what is covered to share with your healthcare provider. This last may be available through your insurance provider’s website or portal, or you can call and request this information. Medications that are FDA-approved to help with chronic weight management (like Wegovy®) may be more likely to be covered by your insurance. [9] If you are looking into off-label medications like Ozempic®, you may need prior authorization before the medication will be covered. [10]

Many plans will also require that patients meet certain circumstances before they qualify for weight loss medications. For example, someone may need a certain BMI or a diagnosis for a related health condition before getting coverage. [11]

Read more about BMI and weight management →

Determining any out-of-pocket costs can help you prepare a budget so you aren’t surprised when you go pick up your first prescription. Depending on your plan, you may have a certain deductible to reach, coinsurance to pay, copays for medications or visits to your healthcare provider, etc. [8] You can find all of this information about your plan online, in your physical insurance paperwork, or by calling your insurance provider. Once you know this information, you will have a better idea of how much a GLP-1 prescription may cost out-of-pocket.

(Feeling lost? Here’s a recap of healthcare basics and terminology)

Something a lot of people don’t realize is that many drugs have specific payment assistance programs in place to lower the cost of their medication. [12] These may not be available to everyone, but some people do qualify if they fall below a certain income or are having an issue with their insurance coverage. Speak to your healthcare provider about any specific PAPS you may qualify for.

Getting coverage from your health insurance provider isn’t always easy. Even after you’ve jumped through hoops to get an appointment with a provider and you’ve compiled a list of medications you’re interested in, there may be roadblocks. Finding a flexible healthcare provider that can help you navigate this process is key.

What some people don’t realize is that insurance plans may require that certain milestones be hit before any refills are covered- meaning you may be required to lose a certain percentage of your pretreatment body weight if you want to keep your coverage. [11] It’s also possible that after losing enough weight, insurance providers may deem the treatment no longer necessary. [11] Fortunately, appeals can be made by your healthcare provider if you do face pushback, so be sure to keep them in the loop.

GLP-1 medications can be extremely useful for treating type 2 diabetes and obesity, and have been shown to improve cholesterol and cardiovascular health. [1-4] Without insurance coverage, these medications can cost upwards of $900 for a month's supply. It’s important to know what specific drugs your health insurance covers and what the stipulations are to qualify for first-time or recurrent use. There may be other out-of-pocket costs associated with your prescription and care visits, so it may be helpful to prepare a budget and be aware of these costs beforehand. If you have trouble getting a specific medication approved, your healthcare provider may be able to help you navigate prior authorization requests, patient assistance programs, and more.

We at Everlywell are determined to offer the best health and wellness solutions from at-home lab testing to virtual care visits. With Weight Care +, Everlywell’s clinical care team helps to identify the best medication for you based on your insurance coverage and health needs. Weight Care+ is a weight management program to help you achieve your weight goals. The program offers support throughout the weight loss process with virtual care visits with a healthcare provider. Your healthcare provider will create an individualized plan for you to ensure you lose weight safely and effectively.