Insurance Denials for Weight Loss Medications

Insurance denials for weight loss medications like Wegovy and Zepbound have been on the rise as insurers looks to stop covering weight loss medications due to rising costs. This move could be somewhat shortsighted however as many policy centers believe that the long term savings of reducing the weight of the 40% of Americans who are clinically obese could far outweigh the medication costs in the short term.

For example the Schaeffer center believes that medicare could save $175billion, yes that’s billion, within 10 years if it covered the new GLP-1 appetite suppressant drugs. It also estimated that America could save $1 trillion as a whole if all eligible americans were giving the treatment.

This news comes on the back of the recent removal of weight loss prescriptions from coverage of North Carolina state employees last month.

And currently it seems that 30% of the employers that cover the medication are looking to restrict the usage to control costs.

If Insurers Could Save So Much, Then Why Aren’t They Covering It?

The main reason is quite simply that when it comes to older american’s the insurers may not actually benefit. For example, if a person who is 55 uses the medication and loses weight over 10 years, by that time they will in the insurers eyes be medicare’s problem not there’s as they will have retired. Meaning the insurers will not actually reap the benefits.

This of course applies more to people nearing retirement age, so why not give it to younger people. The main argument seems to be that long term use hasn’t been studied and that the insurers aren’t aware of potential complications.

One of the worst things is that insurance companies often require patients to try a cheaper and often ineffective option before they offer the more expensive treatment, these also tend to have side effects like diarhea. And of course, if the patient hasn’t complied with said treatment, they are not eligible to receive the better treatment. Which is of course a short sighted cost saving exercise, when we consider the long term costs of obesity.

The Positive News

That said, despite the increase in denials, more insurers overall do offer the weight loss aids than in previous years, with surveys showing 43% are expected to offer it by the end of 2024, whereas it was less than 25% last year.

 How Well Do Weight Loss Aids Work?

Medication

Average weight loss

Cost Per Month

Liraglutide (Saxenda)

11lbs after 14 months

$1,350

Tirzepatide (Zepbound)

41lbs in 18 months

$1,060

Semaglutide (Wegovy)

27lbs after 1 year

$1,348

And whilst some of these improvements may seem reasonably modest, this is of course a significant improvement for many people.

Why Are Claims Being Denied

The most common reasons that contribute to denials include:

Lack of Medical Necessity: Insurance providers often require documented evidence of medical necessity for weight loss medications. This may involve demonstrating a certain body mass index (BMI) or the presence of obesity-related health conditions.Exclusion Criteria: Certain insurance plans have specific exclusion criteria that restrict coverage for weight loss medications. These criteria may include age limits, BMI restrictions, or requirements for participation in weight management programs before considering medication coverage.Formulary Restrictions: Insurance companies maintain a formulary, which is a list of approved medications for coverage. Weight loss medications that are not included in the formulary may be subject to denial.

The Impact on Individuals

These denials for weight loss medications can have significant consequences for individuals. It can hinder their progress towards achieving a healthy weight and managing related health conditions. Without insurance coverage, the cost of weight loss medications are for most prohibitively expensive.

Are there any more affordable alternatives?

Well, not really when it comes to GLP-1 blockers like Wegovy, but if we’re talking about other FDA approved weight loss aids like Plenity, then yes as glucomannan functions the same way for half of the cost. Due to the way it works as an expandable fiber, you need to take it before preparing food, with a pint of water. The trials in which it was not successful generally have not done this. You would need 2 grams at least for an effective dosage, but it can help people feel full with smaller meals.

There is an argument for 5HTP, which has previously been available as a weight loss aid. Although dosing requirements are mixed, there have been multiple successful trials on obese patients. The doses range between 300-900mg. 5HTP works by boosting serotonin levels. There have even been tests done under MRI which showed people were less attracted to unhealthy foods whilst taking 5htp on a brainwave level.

Caffiene is also potentially helpful (that’s without cream and sugar) as it’s been shown to suppress appetite for 3-4 hours after consuming.

Whilst these may not be as good options for individuals hoping for something like zepound the cost of over the counter options containing these ingredients is generally $70, which is certainly more cost effective and better than nothing.

Navigating Insurance Denials

1. Understanding Your Insurance Coverage

The first step in navigating insurance denials is to thoroughly understand your insurance coverage. Review your policy documents, paying close attention to the sections related to weight loss medications. Familiarize yourself with the criteria for coverage, formulary restrictions, and any prior authorization requirements.

2. Gather Supporting Documentation

To strengthen your case for insurance approval, gather all necessary supporting documentation. This may include medical records, BMI measurements, documentation of obesity-related health conditions, and any previous attempts at weight management programs. Providing comprehensive and well-documented evidence of medical necessity can increase your chances of approval.

3. Work with Your Healthcare Provider

Your healthcare provider can be a valuable ally in navigating insurance denials. Collaborate closely with them to ensure that all necessary documentation is collected and submitted. They can also advocate on your behalf, providing additional context and medical expertise to support your case for coverage.

4. Appeal the Denial

If your initial insurance claim is denied, don't lose hope. Most insurance companies have an appeals process in place. Take the time to understand the specific steps required for appealing the denial, including any deadlines for submission. Craft a well-written and compelling letter outlining the reasons for the appeal and providing any additional supporting documentation that may strengthen your case.

5. Consider Alternative Options

In some cases, insurance denials may necessitate exploring alternative options. This may involve considering different weight loss medications that are covered by your insurance plan or exploring other non-medication approaches to weight management. Discuss these options with your healthcare provider to determine the best course of action for your specific situation.


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