Leena Watts
Diet pills, or weight-loss drugs, are often not covered by insurance companies, which deem weight loss a cosmetic need rather than a medical one. However, insurance may cover treatments for conditions where being overweight is a related issue, such as Type 2 diabetes. Some employer-sponsored health plans also cover weight-loss medications, even if the patient doesn't have diabetes or cardiovascular disease. In 2024, coverage for weight-loss medications increased to 44% among large employers with 500 or more employees.
| Characteristics | Values |
|---|---|
| Insurance coverage for weight-loss drugs | Varies by insurance plan and type |
| Commercial insurers' coverage | Unlikely |
| Medicare coverage | Prohibited by law |
| Medicaid coverage | Varies by state |
| Employer-sponsored plans | May cover weight-loss drugs |
| TRICARE coverage | May cover Wegovy and Zepbound with prior authorization |
| Cost of weight-loss drugs without insurance | $1,000+ per month |
| Side effects of weight-loss drugs | Nausea, vomiting, diarrhoea, dizziness, mild tachycardia, headaches |
| Legislation | The Treat and Reduce Obesity Act introduced in 2021; Louisiana and Colorado considered legislation in 2024 |
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What You'll Learn
Weight-loss drugs' high costs
Weight-loss drugs can be expensive, with monthly costs ranging from $69 to over $1,000. For example, a month's supply of Wegovy (semaglutide) costs $1,300, while Ozempic (1.0mg per dose, 4 injections) costs $936 in the US. These high costs can be a barrier for people seeking weight-loss treatment, especially if their insurance does not cover the medication.
In the United States, Medicare is prohibited by law from covering weight-loss drugs, and Medicaid coverage varies by state. Commercial insurers also typically do not cover weight-loss medications, considering weight loss a cosmetic need rather than a medical one. However, some employer-sponsored health plans do cover weight-loss medications, depending on the specific plan and employer. Additionally, some people may be able to lower the cost of weight-loss drugs through health savings accounts (HSAs) or flexible spending accounts (FSAs).
The high costs of weight-loss drugs have sparked debates about insurance coverage. In 2021, House lawmakers introduced the Treat and Reduce Obesity Act, which aimed to expand Medicare Part D coverage to include weight-loss medications. While the legislation did not pass, it reflects a growing recognition of the potential benefits of weight-loss drugs in tackling the obesity crisis.
The demand for weight-loss drugs is increasing, with over a million Britons using medications such as Wegovy and Mounjaro. However, supply problems and concerns about sustainability have been noted, particularly in the UK. As a result, there are worries that people may turn to unregulated online sources for weight-loss medications, despite the associated risks.
While the high costs of weight-loss drugs can be a challenge, there are some options for reducing financial barriers, such as insurance coverage, manufacturer savings programs, and HSA or FSA reimbursements. However, it is essential to carefully consider the potential benefits, risks, and long-term implications of these medications before starting treatment.
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The Affordable Care Act
The ACA does not, however, provide a clear definition of what obesity counseling must include, and insurance coverage for weight loss drugs and surgeries varies. While some insurance plans may cover weight loss medications, it is often challenging to get them covered. Employer-sponsored benefit plans are the most likely to cover these drugs, but even then, only a small percentage of firms do so. Medicare Part D plans must cover some weight loss drugs if the patient has obesity and heart disease or other conditions like diabetes, but not if the drugs are solely for weight loss.
Bariatric surgery is a weight-loss option for people with a BMI of 40 or higher, or a BMI of 35 or higher with serious medical conditions who have been unable to lose weight through diet and exercise changes. The ACA expanded coverage for this type of surgery in 2010, but insurance companies often deny approval for this procedure, and preapproval is usually required. If your insurance company denies coverage for weight loss treatments, your doctor can write an appeal letter explaining the medical necessity of the treatment.
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Insurance plan variations
Insurance coverage for weight loss medications varies depending on the type of insurance plan and the specific medication in question. Some insurance plans may cover weight loss medications, while others may not.
Commercial Insurers
Commercial health plans may cover the cost of prescription weight-loss medications. However, it is important to note that commercial insurers are not required to cover these medications, and coverage may vary depending on the specific plan and the insured's location.
Medicare
Medicare, a federal health insurance program for seniors and people with disabilities, is prohibited by law from covering weight-loss medications that are prescribed solely for weight loss. This includes drugs like tirzepatide and semaglutide, which are meant to be taken indefinitely. However, Medicare Part D, which covers prescription drugs, may include coverage for weight loss medications in some cases. Additionally, patients on Medicare with limited resources may be able to get assistance through the Medicare Part D Extra Help program.
Medicaid
Medicaid coverage for weight-loss medications varies by state. Some states may offer coverage for these medications, while others may not. Additionally, Medicaid may cover nutrition counseling and therapy, which can be beneficial for weight loss.
Employer-Sponsored Plans
Some employer-sponsored health plans may cover weight-loss medications, even if the patient does not have a specific medical condition such as diabetes or cardiovascular disease. However, the coverage depends on the specific plan and the employer's approach. Self-insured plans, which are designed by the employer, are the most common type of employer-sponsored health insurance, and their coverage can vary significantly. For employers who purchase coverage in the large or small-group market, the available options depend on the plans offered by insurers.
TRICARE
TRICARE, the federal health insurance program for U.S. military members and their families, may cover weight-loss medications such as Wegovy and Zepbound if certain prior authorization criteria are met. These criteria include unsuccessful attempts at weight loss through diet and exercise, as well as a pledge to maintain a healthy lifestyle while using the medications.
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Employer-sponsored health plans
Most employer health plans do not cover weight loss drugs, but this is expected to change. A survey of 205 companies by the International Foundation of Employee Benefit Plans found that only 27% provided coverage for weight loss, but 13% of plan sponsors indicated they were considering coverage.
The largest companies in the U.S. are generally self-insured, so they decide on coverage, and for them, cost is a major issue. At $1,500 a month per employee, employers could be paying over $1 million a year for 56 employees. This is a new expense that didn't exist in 2022, and companies are trying to balance maintaining a robust benefits package with keeping costs down.
Some companies that do cover weight loss medication may require prerequisites for coverage, such as a BMI threshold, participation in an exercise or dietary program, or the patient trying other medications first.
If your employer-sponsored health plan does not cover weight loss drugs, you may still be able to get assistance through the manufacturer if you are eligible for savings programs. For example, the websites for Wegovy and Zepbound lay out terms for discount manufacturer programs.
It is important to check the fine print of your employer-sponsored health plan each year during enrollment, as drug coverage and coverage requirements can change annually.
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Obesity screening and counselling
Obesity is a complex issue that often requires medical intervention. Obesity screening and counselling are preventive services mandated by national and state regulations. The U.S. Preventive Services Task Force (USPSTF) recommends screening all adults and children over six years old for obesity. Screening typically includes a BMI measurement, a dietary assessment, and a review of the patient's weight history, dietary patterns, level of physical activity, sleep habits, and mental health.
BMI (body mass index) is a widely used screening tool that calculates weight relative to height and is often supplemented with a waist circumference measurement to assess abdominal fat and cardiometabolic health. These measurements help identify patients who would benefit from weight counselling and indicate potential health risks associated with excess weight. While BMI is a useful indicator, it should be combined with an examination of the patient's muscle mass and body habitus for a comprehensive evaluation.
Obesity behavioural therapy includes initial screening, dietary assessment, and counselling sessions focused on diet and exercise. Counselling aims to empower patients to set and achieve sustainable weight loss goals by addressing the psychological and behavioural aspects of obesity. However, not all healthcare practitioners are trained or comfortable providing counselling, and negative attitudes towards patients with obesity have been noted in the medical community.
In terms of insurance coverage, obesity screening and counselling are generally reimbursable services. Medicare, for example, covers face-to-face visits with qualified practitioners at specified intervals, provided the patient achieves a certain amount of weight loss. However, when it comes to weight-loss medications, insurance coverage is less consistent. While some employer-sponsored health plans and specific state regulations may cover these medications, many commercial insurers, Medicare, and Medicaid typically do not. The perception that obesity is a cosmetic issue rather than a chronic disease influences this coverage gap, despite efforts by medical associations to classify obesity as a disease and advocate for insurance coverage of weight-loss treatments.
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Frequently asked questions
It depends on the insurance type and the specific plan. Medicare, for example, is prohibited by law from covering weight-loss medications. Commercial health plans may cover the cost of prescription weight-loss medications.
Insurance companies often do not cover the cost of weight-loss medications because obesity is considered a cosmetic issue rather than a chronic disease.
Insurance may cover obesity screening, counseling, nutrition therapy, and bariatric surgery.
Patients can comparison shop and look for coupons. GoodRx, for example, lets patients compare prices across pharmacies and find coupons.
Some employer-sponsored health plans cover weight-loss medications, even if the patient doesn't have a condition like diabetes or cardiovascular disease.
