According to the Texas Behavioral Risk Factor Surveillance System, seventy percent of Texans are overweight. By 2030, fifty percent of Americans will have a BMI greater than thirty. One in four are equal to or greater than thirty-five. I suppose we enjoy our Texas tacos a bit too much. However, these studies reveal a serious issue that needs addressing. Of course, our daily behaviors need to change, but what about our health insurance? What if it is more than our habits and meal choices? Health issues are serious and we at CoverMile are here to help you find which health insurance companies cover the medications you require. Through our study, we aim to provide you with information on Ozempic, Wegovy, and other weight loss medications a doctor may prescribe to assist you on your road to a healthy tomorrow.
What are weight loss medications?
There are many types of over-the-counter weight loss remedies. However, lately there are several that have become popular and currently prescribed as diabetic medications. Some of these diabetic medications’ benefits are that they assist with weight loss. You probably have heard ads on the radio and TV. Doctors have been attempting to prescribe these medications to their patients for medical weight loss, however, due to this influx, it has drained the pool of those who need the medication for diabetes. Thus, drug companies have had to increase the prices, making the drug harder to obtain. Insurance companies now require patients to prove medical necessity among the top medications. This means that if one does not have diagnosed diabetes, one will most likely not be able to obtain the drug they are seeking; there are exceptions as drug companies are opening doors to those who desire medication for weight loss. Here are some of the most popular medications on the market:
The drug Semaglutide has many forms and substitutions. One of the sidekicks from the Bobby Bones radio program, Lunchbox, promotes an off-use weight loss treatment. It has a Semaglutide base but adds other ingredients. This injection or weight loss pill method is marketed as a safe, and effective alternative to Ozempic.
Are There Restrictions on How Weight Loss Medications Are Covered Under Obamacare in Texas?
Under the Affordable Care Act, both individual and small group health plans are required to cover a minimum of one drug in each USP category and class, either that or the plan must match the Essential Health Benefit (EHB) benchmark plan in that state.
That being said, when it comes to the classes of drugs that include weight loss, these categories are not included under EHB rules. So, coverage, specifically for weight loss is left up to the states. The final rule published in April of 2024 by HHS and the Department of Treasury includes changes that make it cheaper for states to update their EHB benchmark plans to include new benefits, expanding new benefits one of which is obesity care.
Each Marketplace insurance company treats weight loss and medications fairly the same. However, new regulations allow them to include benefits for those seeking weight loss treatment. It is always wise to research each company because how each cover weight loss will be different.
Under BCBS of Texas, both Ozempic and Mounjaro are listed under Antidiabetics. This means that a member would not be prescribed for weight loss alone. BCBS requires prior authorization as well as places a quantity limit on this medication injection. For 2024, BSBS began to cover Wegovy for weight loss. It has a quantity limit and must be approved by your physician. While BCBS covers Mounjaro, they have yet to approve Zepbound.
With UnitedHealthcare, both Ozempic and Mounjaro are under Antidiabetics. One would need to be diagnosed with diabetes to be prescribed these medications. There is also a quantity limit with UHC. They’ve approved the injection Wegovy, with an injector supply limit, but have yet to approve Zepbound.
Oscar Insurance only allows Antidiabetics access to Ozempic. One needs a diabetic diagnosis to obtain a prescription. There is a quantity limit, prior authorization is required, and step therapy is a must. Mounjaro is not on their formulary list, thus nor is Zepbound. Also, for 2024, Wegovy joined their formulary list as covered for weight loss as medically necessary.
Aetna covers both Ozempic and Mounjaro as antidiabetic medications. For these at a diabetic level, one needs preauthorization and there is a quantity limit. However, Aetna extends coverage for Wegovy injections for anti-obesity. Preauthorization is required. As far as we can see Aetna is the only provider that will cover Zepbound.
Is Weight Loss Medication Covered Under Group Medical Insurance?
Each type of Affordable Care Act insurance in Texas treats weight loss coverage a bit differently. Let’s break each type down and review how this will impact one seeking coverage for medications such as Ozempic and Wegovy.
The US FDA has released two diabetes medications for weight loss use. These injection medications are Wegovy or Semaglutide and Zepbound. Zepbound can also be in pill form. Both are approved for ages twelve and over for chronic weight management. As we mentioned, many other methods are used to treat off-label. These other options will vary depending on the state and insurance company.
A study conducted by Accolade found that while 81 percent of human resource decision-makers feel employees would be interested in GLP-1 coverage, only 25 percent offer it today. The main obstacle is the lack of trusted information and the perceived high cost of medication. Forty-eight percent said that if more information were available, perhaps they would consider covering GLP-1s; and 38 percent cited the cost barrier was an issue with providing coverage. Overall, 81 percent feel their employees would be interested, though.
Of those already providing coverage, 75 percent report a higher employee satisfaction; 58 percent have increased engagement in other well-being programs, and 57 percent saw an improvement in other health conditions.
Medicaid regulations are left up to each state. However, only fifteen states have state-based Medicaid programs that cover weight loss medication, and only four others cover meds under a company-based Medicaid plan. Even though weight loss drugs can be excluded from coverage, some states cover these drugs for severe obesity, with a comorbidity, or other restrictions. GLP-1 advocates have received approval, however, for treatment of type 2 diabetes and to be covered under Medicaid.
If you are being treated for diabetes and using medications such as Ozempic and Wegovy as prescribed, then yes, Medicare will cover them. However, if they are intended for weight loss, then Medicare will not cover them to treat such illnesses. This is a law that dates back to Medicare Part D. An April 1, 2024, memorandum now allows Part D recipients to receive coverage for Wegovy weight management medication.
Another form of insurance that is available is Short Term Health Insurance. However, with STH, if you have a preexisting condition, you will not have coverage. The purpose of a Short-Term plan is to help you bridge the gap between losing health insurance from one source and obtaining it with another. It is there to help you with illnesses and emergency issues, not health maintenance. So, if you have diabetes or are seeking a weight loss regimen that includes prescription coverage, then this would not be your best avenue.
What are the Risks Associated with Taking Ozempic?
As with most medications, especially when one strays from their intended usage, there are risks with thanking them. Some of the warnings that come with taking Ozempic.
As with all medications, there are risks. Some of the warnings that come with taking Ozempic are:
Common adverse reactions can be:
As of April 2024, over 17,000 cases have been filed against manufacturers of Ozempic. Of these cases 7,850 are serious, and 222 have led to death. Yet, in Jan 2024, the FDA released a safety communication that some of the issues linked to Ozempic and Wegovy usage are still being investigated.
In a Good Morning America interview, the COO of the Obesity Action Coalition, James Zervios said, “These are medications that need to be prescribed in a medical setting and under the guidance of a health care provider. These are not medications that are out there for vanity use. These are really meant for people that are dealing with this disease.”
Summary
As more individuals are seeking alternative medicine like Ozempic to enhance their weight loss program, this has hurt the diabetic community. However, there are methods to obtain the health insurance coverage you seek through medications such as Wegovy. We at CoverMile desire to help you through the process of finding the best health insurance company and coverage for medications that will provide you on your road to a healthy 2024.
Frequently Asked Questions
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Is Ozempic safe to take?
As with all medications taken off-label and outside of their intended use, there are always risks. The common side effects of taking Ozempic are nausea, stomach pain, vomiting, diarrhea, and constipation. Those who use Ozempic for weight loss saw a greater risk of these conditions. Use of Ozempic can also lead to severe allergic reactions, vision problems, and pancreatitis. The FDA also has a warning of thyroid C-cell tumors for any user.
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Is Semaglutide covered by Medicare?
Semaglutide is a diabetic drug that has other brand names. Two are Ozempic and Wegovy. Ozempic is covered when used as a treatment for diabetes. As of April 1, 2024, Wegovy was approved for treatment for weight loss and covered by Medicare.
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How much does Ozempic cost without insurance?
In the US. Ozempic has one of the highest costs in the world. Without health insurance, the list price for the diabetic drug is $936 per month. In other countries, it ranges from $83 to $169. These list prices are not generally what people will pay as manufacturers will often provide rebates or prescription coupons. The cost with insurance will vary by company and plan selected.
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Does health insurance cover Wegovy for weight loss?
Yes. As of April 1, 2024, Wegovy was added to most health insurance companies’ formulary drug lists under weight loss coverage. One still needs to adhere to the medical need for the medication.
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Which insurance companies cover Ozempic?
All marketplace insurance companies in our research cover Ozempic for diabetic use. None of them allow Ozempic usage for weight loss unless diabetic health is the root cause of the prescription use.
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Which insurances cover Zepbound?
As of the writing of this article, only one company on the list covers Zepbound, Aetna. This is a new drug and sister to Mounjaro. While its base is the same drug, its coverage is not the same. It is intended to work like Wegovy in that it is a medication designed for those with chronic weight issues instead of targeting those with diabetes.
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What Marketplace health insurance company covers Mounjaro?
In our research, all Affordable Care Act insurance companies but Oscar Insurance covers Mounjaro in their formulary list. Mounjaro is only prescribed as a diabetic medication and cannot be used for weight loss alone.
