Have you implemented diet, lifestyle changes and want to lose weight but are nervous about the cost of medicine?
We understand that medication costs are a concern.
And we know that getting straight information about your prescription treatment options is confusing.
But,
Truth is, the cost of weight loss medications can vary depending on your specific insurance plan and coverage.
The Good News: The Weight Sense care team is here to help!
During our visits, we work diligently to:
Submit prior authorizations: If needed, we’ll handle the paperwork to get approval for coverage (if on your health care plan).
Advocate on your behalf: We’ll work with your insurance company to ensure you get the best possible coverage.
Even better news: If your first-choice medication isn’t covered, available, or affordable, your doctor will be able to recommend alternatives. Your doctor will consider your medical history and what best fits your health goals to find an affordable option.
But if you want to know your insurance coverage options even before you see us, then this article is for you.
During your first visit with Dr. Shah the first goal is to determine if you have overweight or obesity. We spend time to really determine the factors driving your weight gain or blocking your weight loss. Then we proceed to your treatment options. The first pillar of weight loss treatment includes healthy eating, physical activity and behavior strategies tailored to your specific needs.
The next tier of weight loss treatments is focused on specific medical interventions to help you with sustainable weight loss. This includes a review of medications and even medical interventions such as surgery (Dr. Shah is not a surgeon, but we can refer you).
Understanding Anti-Obesity Medications
There are more medications than just “injectable weight loss medications”.
Options to treat obesity include the following medications:
Anti-obesity medications are prescription treatments designed to help individuals with obesity. Generally insurance companies use definitions such as BMI to determine coverage options.
These medications work through various mechanisms:
- GLP-1 Agonists (Wegovy®, Saxenda®): Help you feel fuller and reduce appetite
- Dual GIP/GLP-1 Receptor Agonist (Zepbound™): Targets two receptors to increase fullness and reduce appetite
- Combination Medications (Qsymia®, Contrave®): Work on different brain pathways to reduce hunger and control cravings
- Lipase Inhibitor (Orlistat): Blocks fat absorption in the digestive system
- Appetite Suppressants (Phentermine, Phendimetrizine, Diethylpropion): Reduces appetite
Insurance Coverage Basics
Insurance coverage for anti-obesity medications varies widely.
Coverage depends on:
- Your specific insurance plan
- Whether your plan considers obesity treatment a covered benefit
- Whether the medication is on your plan’s formulary or it’s approved medication list for your medical condition (such as obesity, sleep apnea, cardiovascular disease)
- Your specific medical history, weight and BMI
Remember that even when medications are covered, there may be requirements such as prior authorizations or step therapy protocols. Step therapy means your insurance company may require you to try certain medications before approving the first medication.
How to Call Your Insurance Company & Find Out Your Weight Loss Medication Treatment Options
- Find your insurance card and locate the customer service number (usually on the back)
- Prepare information before calling:
- Your member ID number
- Date of birth
- The specific medications you want to inquire about
- Take notes during the call:
- Write down the date and time of the call
- Get the name of the representative you speak with
- Record the information provided
- Request written confirmation of coverage information if possible
Key Questions to Ask
When you call your insurance company, ask these specific questions:
- “Do I have prescription drug coverage for anti-obesity medications?” (Yes/No)
- Then go through each medication and ask if you have coverage (use chart above).
- “Do I have a deductible for medications?” (Yes/No)
- If yes: “What is my yearly deductible?” $_______
- “How much of my deductible has been met so far this year?” $_______
- For each medication you’re considering, ask:
- “Is [medication name] covered under my plan?” (Yes/No)
- If yes, for what medical condition?
- “Is it a preferred medication?” (Yes/No)
- “What is my copay or coinsurance for this medication?” $_______
- “Is prior authorization required?” (Yes/No)
- “Are there any step therapy requirements?” (Yes/No)
- “Are there any quantity limits?” (Yes/No)
- “Is [medication name] covered under my plan?” (Yes/No)
Understanding Insurance Terminology
- Deductible: Amount you must pay before insurance begins covering costs
- Copayment: Fixed amount you pay for a covered medication
- Coinsurance: Percentage of costs you pay after meeting your deductible
- Medication tier: Classification system that determines your cost share
- Out-of-pocket maximum: Annual limit on what you pay before insurance covers 100%
- Prior authorization: Doctor’s request to insurance for coverage approval
- Quantity limit: Restriction on the number of pills/doses covered in a time period
- Step therapy: Requirement to try less expensive options before coverage of more expensive medications
Manufacturer Savings Programs
If insurance coverage is limited or unavailable you still have options to access medications. The pricing below may change and it is best to visit zepbound.com or wegovy.com for most up to date information.
- Wegovy® (semaglutide)
- Pay as little as $0 per month with commercial insurance (maximum savings of $225 per 28-day supply)
- Available through NovoCare for $499 per month (all doses: 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, and 2.4 mg)
- Zepbound™ (tirzepatide)
- Pay as low as $25 for a 1-month supply with commercial insurance coverage
- $550 per month without insurance coverage
- Through Lilly Direct: $349-$499 per month for self-pay (pricing varies by dose)
- $349 per month for 2.5 mg
- $499 per month for 5 mg, 7.5 mg, and 10 mg doses
- Qsymia® (phentermine-topiramate)
- Available from mail-order pharmacies at approximately $98/month
- Contrave® (naltrexone-bupropion)
- Available from mail-order pharmacies for approximately $99/month
Generic Alternatives
- Phentermine and topiramate (Qsymia® components)
- May cost less than $80/month when prescribed separately
- Naltrexone and bupropion (Contrave® components)
- May cost less than $99/month when prescribed separately
- Generic phentermine(GoodRx coupon)
- Usually available for less than $30 for a 30-day supply
Pharmacy Discount Programs
- Services like GoodRx can provide significant savings on prescriptions
