WEIGHT LOSS MEDICATIONS

• Weight loss medications are indicated for patients who have a BMI of >30 OR >27 with weight related comorbidities

• Weight related comorbidities include:  History of heart disease or stroke, diabetes, high blood pressure, high cholesterol, sleep apnea, fatty liver disease, chronic kidney disease. 

• Weight loss medications are used in combination with lifestyle modification (healthy diet and exercise habits) to promote healthy weight.

• Weight loss medications can be used as an alternative or in conjunction with bariatric surgery to optimize weight loss. 

Many FDA-approved weight loss medications require something called a prior authorization (PA) before your insurance company will cover them. 

A prior authorization is a process required by your insurance company to determine whether a medication is medically necessary and eligible for coverage.  Before approving certain prescriptions–especially new or or higher–cost medications–insurance plans often require your health care provider to submit documentation that shows:

• Your medical history and BMI

• Weight-related health conditions such as diabetes, hypertension, sleep apnea, etc.

• Previous weight loss attempts

• Lab results or clinical notes

• Only after reviewing this information does the insurance company decide whether to approve or deny coverage. 

Unfortunately, prior authorizations for weight loss medications can be complex and time-consuming.  Plan on at least 2 weeks for an authorization to be processed.

Some insurance plans do not cover anti-obesity medications at all (excluded from plan).  Others may limit coverage to certain diagnoses or BMI thresholds.

Insurance criteria can change frequently.  We are here to help navigate this, but we can not change your insurance company's criteria.

Many plans require patients to try other medications first before approving newer treatments.

1. Know your insurance benefits:  Contact your insurance prior to your appt to ask:

   • Does my plan cover anti-obesity / weight loss medications?

   • Are there BMI requirements?

   • Are specific diagnoses required?

   • Is step therapy required (trying other medications first)?

   • Are certain medications excluded?

2. Provide medical history / records

   • Weight and height are used to calculate your BMI.  Insurance will have specific BMI criteria for weight loss medications.

   • Provide documentation of exercise habits.  Insurance will require formal exercise efforts usually totaling 150 minutes per week (30 min, 5 days per week)

   • Document food habits on a food tracker / journal.  Insurance will require that you make dietary changes and reduce calories prior to approving weight loss medications. 

   • Provide documentation of weight related comorbidities such as sleep studies for sleep apnea, hospital reports for heart disease or stroke history, imaging or labs for fatty liver disease or kidney disease.    

   • Provide records of previous weight loss efforts such as Weight Watchers or previous medication trials.

3. Be consistent with follow up visits.

   • Ongoing documentation of lifestyle modification and weight loss success are required for your insurance to renew your authorizations.

   • Failure to lose adequate weight or participate in healthy lifestyle modification frequently results in denial of authorization renewals.

Even when medical criteria are met, requests may be denied.  Laws and regulations regarding insurance coverage for weight-loss medications are constantly evolving. It's crucial to stay informed about the latest developments and advocate for yourself.

• Appeal the denial: If your request is denied, you have the right to appeal the decision.   Contact your insurance company to start an appeal process.

• Write a letter of advocacy:  Visit the Obesity Action Coalition to learn how to advocate for insurance coverage and obesity management.  

• Explore cost-saving options: If your appeals are unsuccessful or you need to pay out-of-pocket, consider these strategies:

  • GoodRx coupons and discount programs:  These can significantly reduce the cost of weight-loss medications, potentially bringing monthly costs down to several hundred dollars.

  • Manufacturer savings cards:  Many drug manufacturers offer savings cards or patient assistance programs that can help offset the cost of their medications.

  • Utilize HSA/FSA:  You can use your Health Savings Account or Flexible Spending Account to pay for eligible prescription medications, including those for weight loss.