It’s not ethical, but it’s perfectly legal for health insurance companies to exclude coverage for anti-obesity medications and obesity treatment (medical office visits that address weight). Understanding what your policy covers and excludes is vital when hoping to use health insurance for your treatment
Sadly, most health plans in our area DO NOT cover anti-obesity medications. If this is the case, no amount of pleading from our end (in the form of prior authorizations or appeals) will convince them. Trust us, we have tried and tried and tried…
If you are interested in using one or more anti-obesity medications as part of your treatment, before coming in for your first visit, it’s important to understand your coverage. The prescribe and pray method (having us send a prescription to your pharmacy, hoping it will work) usually results in frustration and means you have to wait until your next visit to discuss alternatives.
Steps to Figuring Out Your Coverage:
1 Get access to your plan’s formulary. You should be able to access this from your plan’s website or from your HR department
2 Search the formulary for Wegovy, Saxenda, Qsymia, Contrave and Zepbound (this doesn’t mean we are going to prescribe any of these medications – we are just trying to determine if any are covered!)
3 Find out what your portion of the cost will be for each one. This may be listed as a copay tier or fall under something called “shared cost.” If this isn’t disclosed on your insurance company’s website, call your carrier and ask a representative. Be persistent. Sometimes a medication is listed as “covered” but you are responsible for paying the entire cost.
**** Bring this information to your first visit so your clinician can use it to help guide decision-making about anti-obesity medications
If Your Plan Covers Anti-Obesity Medications:
If you and your clinicians decide that starting an anti-obesity medication is the best course of action and your insurance is willing to pay for the medication, chances are good that a prior authorization (PA) will be required before you can actually acquire the medication. If it’s required, a PA will automatically be started when the prescription is received by the pharmacy.
*** Please note: it can take up to two weeks (or more, in some cases) for PAs to process. This is not due to anything on our end and calling/emailing won’t cause them to process any faster!
***If a PA is denied because the plan doesn’t cover anti-obesity medications, no amount of appealing will cause them to reverse their decision (trust us, we’ve tried). If you want us to file an appeal on your behalf, we are happy to do it. However, because it takes a significant amount of time on our end, we charge $25 for filing the appeal – regardless of the outcome.
*** We DO NOT prescribe new anti-obesity medications between appointments (in response to phone calls or portal messages). Changes in medications require a face-to-face conversation with one of our Obesity Medicine Specialists, which means it must be done during a visit. This is one of the many reasons we recommend frequent visits at the onset of treatment.
*** If you have a plan other than BCBS or United (there are dozens!), chances are that the process of checking your formulary is VERY similar to the process described above. Watch one or both videos (they are very short) and then apply that information to your plan website!
Semaglutide is the generic name for an anti-obesity medication that has recently gotten lots of public attention. Semaglutide exists in three forms:
- Ozempic (FDA-approved for treating type 2 diabetes)
- Wegovy (FDA-approved for treating excess weight)
- Compounded (not-FDA-approved for anything at all!)
If your formulary includes Ozempic, it DOES NOT mean it will be covered. Although earlier this year, many people were using it off-label to treat obesity, plans have put us strict guardrails around accessing this medication and it is only covered for patients with a diagnosis of type 2 diabetes (and lab evidence to support it).
Due to concerns about safety and lack of quality data, we DO NOT write prescriptions for compounded semaglutide. We have other tools in our toolbox for treating excess weight that have much better safety profiles.
If you have CVS Caremark:
We have recently learned that some employers that use CVS Caremark and cover anti-obesity medications have opted into a program that, beginning November 1, 2023, will require all patients receiving these anti-obesity medications to get them via the CVS Caremark program. This is a brand-new program created by CVS and we have no idea what this program entails. Their marketing materials claim that participants will have access to a dietician and “provider oversight”, but at this point, we have no idea what this means, and they have not advertised anything about utilizing clinicians with advanced training in Obesity Medicine, which is sad (but not surprising). We do know that the marketing materials aimed at the employers claim that they will try and dissuade patients from utilizing anti-obesity medications. If you have CVS Caremark, look into this right away and if you disagree with it, talk to your employer/HR department about opting-out.
If you want to appeal to your employer to cover anti-obesity medications:
Most employers that provide their employees with a health insurance policy want their employees to be healthier. Not only because it’s good for their people’s well-being overall, but also because employers offering health insurance are required to pay at least half of the premiums. Having healthier employees saves them money too. Most employers can’t afford to broadly cover all anti-obesity medications – with the amount of med spas writing prescriptions and online companies offering medications without oversight, the risk/benefit ratio simply doesn’t support it. However, they may be willing to help with the cost for an employee participating in an evidence-based program deployed by clinicians with advanced training in Obesity Medicine – who utilize anti-obesity medications in a prudent way, as part of a comprehensive program to improve health (and decrease healthcare costs). CLICK HERE to download a sample letter that you can provide your HR department to appeal for coverage.
Health insurance plans can (and do) exclude treatment of excess weight from their plan design. Most plans have a standard clause to this effect listed in their exclusions. We don’t think it’s ethical (and it certainly demonstrates bias), but, sadly, it’s legal.
Until 2023, treatment of excess weight was covered by health insurance if the healthcare team was also addressing health conditions related to excess weight (such as high blood pressure, high cholesterol, or diabetes). However, at the beginning of 2023, Blue Cross Blue Shield plans began denying coverage for most medical office visits – even when patients also received treatment for other diseases (and our charting and coding supported it). We have appealed this multiple times to no avail. With the cost of group health plans taking the biggest jump in over 10 years, health insurance companies are trying to cut costs wherever they can, and we anticipate this process to become more widespread in 2024.
Throughout 2023, denying medical care and retracting previously paid claims for medical care (yes, they can do this for up to 12 months) has caused many of our patients to suffer significant financial hardship. Not only has it forced them to pay for our visits out of pocket, but it has also impacted previously-met deductibles, resulting in unexpected bills from other healthcare companies.
Because of this, we have canceled our contract with Blue Cross Blue Shield and are no longer in-network with any Blue Cross plans. We simply can’t remain in a contract with a company that engages in such unethical practices.
Although Blue Cross Blue Shield was the only carrier engaging in these shady practices in 2023, we anticipate the other major carriers will likely engage in similar practices in 2024 – in an attempt to contain costs. We don’t think any plan is safe. We are encouraging all our patients who wish to use health insurance for their care to fully understand their plan and be comfortable with the risks associated with using it.
Steps to Figuring Out Your Coverage:
1 Check to make sure our physicians are in-network. We don’t understand it, but not all plans include nurse practitioners in their list of in-network providers. If our physicians are on there, rest assured the nurse practitioners are too.
2 Check your plan to see if you have a clause that excludes treatment of obesity or “weight loss services.” Your plan document is likely several hundred pages long. Although you should technically read the whole thing cover to cover, it’s likely that any exclusion pertaining to obesity treatment is in the section titled “exclusions” and should be easy to find. If your plan contains this exclusion, you are at risk of having your carrier deny your visits – immediately or up to a year from now.
3 Call the number on the back of your insurance card and talk to a plan representative. Ask them if your plan contains an “obesity exclusion.” If they tell you it doesn’t, write down the date and time you called or get a call reference number. If you use your insurance for the visit and they deny payment, you can appeal it using this call as proof that coverage was promised. If they can’t tell you this or you have an exclusion, we recommend paying out of pocket for your care with us.
Most non-cosmetic services performed by licensed healthcare providers are covered by traditional HSA/FSA plans. Since every plan is unique, we cannot guarantee coverage, but many of our patients use these types of plans to cover treatment. Similar to using traditional insurance, we encourage all of our patients wanting to use their HSA/FSA plan to verify coverage prior to their appointments.
If you want to appeal to your employer to cover obesity treatment visits:
Most employers that provide their employees with a health insurance policy want their employees to be healthier. Not only because it’s good for their people’s well-being overall, but also because employers offering health insurance are required to pay at least half of the premiums. Having healthier employees saves them money too. Many employers have no idea that their plan excludes medical office visits with clinicians with advanced training in Obesity Medicine. They may be shocked to learn that their employees are being denied services that have significant potential to make them healthier and lower healthcare costs. They may not be able to change their plan design partway into the benefit year, but they may be willing to help with the cost for an employee participating in an evidence-based program deployed by clinicians with advanced training in Obesity Medicine. CLICK HERE to download a sample letter that you can provide your HR department to appeal for coverage.