GLP-1 Insurance Coverage

GLP-1 Insurance Coverage Overview

The Coverage Problem

The paradox: GLP-1 medications are FDA-approved, highly effective (15-22% weight loss), and reduce cardiovascular disease and diabetes risk by 20-30%, yet:

❌ Medicare: Zero coverage by federal law (affects 55 million) ❌ Medicaid: Coverage in only 13 states (varies widely) ❌ Commercial insurance: 60-75% of plans explicitly exclude weight loss medications ❌ Employer plans: Most have “obesity treatment” exclusions

Result: Only 25-40% of Americans with commercial insurance can get GLP-1s covered for weight loss.

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Coverage by Medication and Indication

Medication	FDA Indication	Insurance Coverage Rate	Typical Copay
Ozempic	Type 2 diabetes	80-90%	$25-100
Mounjaro	Type 2 diabetes	80-90%	$25-100
Wegovy	Weight loss only	25-40%	$25-100 if covered
Zepbound	Weight loss only	25-40%	$25-100 if covered
Saxenda	Weight loss only	15-30%	$25-100 if covered

The loophole: Ozempic and Mounjaro (diabetes drugs) are widely covered and often prescribed off-label for weight loss.

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Medicare Coverage (Age 65+)

Federal Law Exclusion

Medicare Part D CANNOT cover:

• Any medication prescribed solely for “weight loss or weight gain”
• Explicit federal law since 1965 Social Security Act
• Applies to all 55 million Medicare beneficiaries
• No exceptions regardless of medical necessity

Why this law exists:

• 1960s-70s “diet pills” (amphetamines) were dangerous and abused
• Congress banned Medicare coverage for all weight loss drugs
• Law never updated despite modern, safe GLP-1s

Legislative efforts:

• Treat and Reduce Obesity Act (pending since 2013)
• Would allow Medicare Part D to cover FDA-approved obesity medications
• Has bipartisan support but not yet passed
• Estimated to pass 2025-2027 (optimistic)

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What Medicare DOES Cover

✅ GLP-1s prescribed for diabetes:

• Ozempic (semaglutide) for type 2 diabetes
• Mounjaro (tirzepatide) for type 2 diabetes
• Coverage through Part D prescription plans

Costs with Medicare Part D:

• Deductible phase: $0-590 (you pay 100% until deductible met)
• Initial coverage: $47-100/month (25% coinsurance)
• Coverage gap: $200-520/month (25% coinsurance)
• Catastrophic phase: $11-20/month (5% coinsurance)

Annual out-of-pocket: $1,200-3,500 depending on plan

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Off-Label Prescribing Strategy for Medicare

Can Medicare beneficiaries get GLP-1s for weight loss?

Sort of—through diabetes indication:

Strategy:

1. If you have type 2 diabetes or prediabetes (A1C ≥5.7%)
2. Doctor prescribes Ozempic or Mounjaro for diabetes management
3. Weight loss is “secondary benefit”
4. Medicare covers under diabetes indication

Success rate: 70-80% if you legitimately have diabetes/prediabetes

Won’t work if:

• A1C <5.7% (no diabetes/prediabetes)
• No documented diabetes diagnosis
• Prescription clearly states “weight loss only”
• Asking for Wegovy/Zepbound (weight loss only)

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Medicare Advantage Plans

Some Medicare Advantage (Part C) plans cover GLP-1s for weight loss:

• 10-15% of Medicare Advantage plans include weight loss coverage
• Check plan’s formulary before enrolling
• Rare but increasing

Examples:

• Some Kaiser Permanente Medicare Advantage plans
• Humana Medicare Advantage Select plans (limited)
• UnitedHealthcare Medicare Advantage (select plans)

Most don’t cover weight loss indication—check during open enrollment.

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Medicaid Coverage (Low Income)

State-by-State Variation

Medicaid coverage varies dramatically by state:

13 states with comprehensive GLP-1 weight loss coverage:

• California, Connecticut, Delaware, Louisiana, Maryland, Massachusetts, New Jersey, New York, North Carolina, Vermont, Virginia, Washington, West Virginia

15 states with limited coverage (strict criteria, prior auth):

• Arizona, Colorado, Florida, Illinois, Indiana, Kentucky, Maine, Michigan, Minnesota, Nevada, Oregon, Pennsylvania, Rhode Island, Tennessee, Wisconsin

22 states with NO coverage for weight loss:

• Alabama, Alaska, Arkansas, Georgia, Hawaii, Idaho, Iowa, Kansas, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Ohio, Oklahoma, South Carolina, South Dakota, Texas, Utah, Wyoming

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Medicaid Diabetes Coverage

All 50 states cover GLP-1s for diabetes:

• Ozempic and Mounjaro covered when prescribed for type 2 diabetes
• Standard Medicaid copays: $0-4/prescription
• Prior authorization required in most states

Weight loss as secondary benefit works better with Medicaid in non-coverage states.

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Commercial Insurance Coverage

Coverage Rates

By plan type:

• Employer plans with obesity coverage: 25-40%
• Employer plans without obesity exclusions: 60%+ (but don’t actively cover either)
• Individual marketplace plans: 20-35%
• Plans in states with mandates: 70-90% (fully-insured only)

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Common Exclusions

Most commercial plans explicitly exclude:

❌ “Drugs prescribed for weight reduction or control” ❌ “Medications for obesity or weight management” ❌ “Appetite suppressants” ❌ “Cosmetic or lifestyle drugs”

Even if exclusion exists, some plans cover if:

• Prescribed for diabetes (covered indication)
• Required by state mandate
• Employer opts into coverage
• Medical necessity demonstrated (rare)

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Major Insurers

UnitedHealthcare:

• 30-40% of plans cover weight loss GLP-1s
• Covers in mandate states
• Strict prior authorization (BMI ≥30)
• $25-75 copay if covered

Anthem Blue Cross Blue Shield:

• 25-35% of plans cover
• State-by-state variation
• Prior authorization required
• $25-100 copay if covered

Aetna (CVS Health):

• 35-45% of plans cover
• More lenient in some regions
• Covers Wegovy more often than Mounjaro/Zepbound
• $25-75 copay

Cigna:

• 20-35% of plans cover
• Very restrictive prior authorization
• High denial rates initially
• $25-100 copay if approved

Kaiser Permanente:

• 40-60% of plans cover
• Integrated system = easier approval
• Emphasis on lifestyle program participation
• $30-60 copay typically

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Checking Your Specific Coverage

3 ways to confirm coverage:

1. Call member services:

• Number on back of insurance card
• Ask: “Does my plan cover Wegovy or Zepbound for weight management?”
• Get reference number for the call

2. Check online formulary:

• Log into insurance portal
• Search drug list for “Wegovy,” “Zepbound,” “semaglutide,” “tirzepatide”
• Look at “tier” (Tier 2-3 = covered, “Not covered” = excluded)

3. Ask your provider to check:

• Medical assistant can submit benefits verification
• Gets exact coverage determination
• Takes 1-3 business days

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State Insurance Mandates

States with GLP-1 Coverage Mandates (2025)

6 states require coverage as of 2025:

1. New Jersey (2023)

• First state to mandate
• Fully-insured plans only
• Prior authorization allowed
• Covers Wegovy, Saxenda, other FDA-approved

2. Connecticut (2024)

• Fully-insured plans
• BMI ≥30 or ≥27 with comorbidity
• Reasonable copays required

3. Delaware (2024)

• All fully-insured health plans
• Prior authorization allowed
• Standard medical copay tiers

4. Maryland (2024)

• Fully-insured plans
• Comprehensive obesity treatment coverage
• Includes GLP-1s and other weight loss medications

5. Vermont (2024)

• Fully-insured commercial plans
• Prior authorization criteria defined
• Must cover if criteria met

6. West Virginia (2024)

• Fully-insured plans
• Obesity treatment mandate
• Includes GLP-1 medications

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Pending State Legislation (2025)

15+ states considering GLP-1 coverage mandates:

Strong prospects (likely to pass 2025-2026):

• California (AB 2085)
• New York (multiple bills)
• Massachusetts (H.2118)
• Illinois (SB 2499)
• Pennsylvania (HB 1620)

Under consideration:

• Colorado, Hawaii, Minnesota, Oregon, Rhode Island, Virginia, Washington

If your state passes mandate: Coverage required within 6-12 months for fully-insured plans.

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Self-Insured vs Fully-Insured Plans

CRITICAL DISTINCTION:

Fully-insured plans (40% of workers):

• Employer pays insurance company premium
• Insurance company bears risk
• State mandates apply
• Example: Small businesses, union plans

Self-insured plans (60% of workers):

• Employer directly pays claims
• Insurance company just administers
• Exempt from state mandates (ERISA preemption)
• Example: Large corporations, Fortune 500 companies

Even if you live in mandate state, coverage not required if employer is self-insured.

How to check:

• Look at your insurance card: “Administered by [Insurer]” = likely self-insured
• Call HR benefits department
• Check Summary Plan Description (SPD)

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Prior Authorization Requirements

Typical Prior Authorization Criteria

Insurance requires ALL of the following:

1. BMI requirements:

• BMI ≥30 (obesity), OR
• BMI ≥27 with at least one weight-related comorbidity:
  • Type 2 diabetes or prediabetes
  • Hypertension
  • Dyslipidemia (high cholesterol)
  • Cardiovascular disease
  • Sleep apnea
  • Non-alcoholic fatty liver disease (NAFLD)

2. Prior treatment failures:

• Documented 3-6 months of:
  • Diet and exercise program
  • Behavioral counseling or weight loss program
• No adequate response (weight loss <5%)

3. Medical necessity documentation:

• Provider’s clinical notes
• Weight/BMI history
• Comorbidity diagnoses
• Lab results (A1C, lipids, etc.)
• Cardiovascular risk factors

4. Exclusion criteria (automatic denial if present):

• History of medullary thyroid cancer
• Multiple endocrine neoplasia type 2 (MEN 2)
• Pregnancy or breastfeeding
• Contraindications to GLP-1s

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Prior Authorization Timeline

Day 0: Provider submits prior authorization request

Day 1-3: Insurance reviews clinical documentation

Day 3-7: Decision communicated

• Approved: Prescription can be filled
• Denied: Reason provided, appeal rights explained

If denied: Appeal process (see below)

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Approval and Denial Rates

First-attempt approval: 40-60%

Common denial reasons:

1. Plan doesn’t cover weight loss medications (50% of denials)
2. BMI doesn’t meet threshold (20%)
3. Insufficient prior treatment documentation (15%)
4. Contraindications or exclusions (10%)
5. Administrative errors (5%)

Appeal success rate: 30-50%

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Appealing Insurance Denials

When to Appeal

Appeal if denial reason is: ✅ Insufficient documentation (provider can add more) ✅ Prior treatment history unclear (provide better records) ✅ Medical necessity not established (stronger clinical justification) ✅ Administrative error (wrong BMI calculated, etc.)

Don’t appeal if: ❌ Plan explicitly excludes obesity medications (won’t change) ❌ You don’t meet BMI criteria (unless BMI was miscalculated) ❌ Contraindication exists (safety issue)

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Appeal Process

Step 1: Provider submits appeal (within 180 days of denial)

• Includes additional documentation:
  • Detailed clinical notes
  • Weight history with dates
  • Diet/exercise program documentation
  • Comorbidity evidence
  • Scientific literature supporting GLP-1s
  • Letter of medical necessity

Step 2: Insurance reviews appeal (15-30 days)

• May request additional information
• Internal review by different reviewer
• Clinical pharmacist or medical director review

Step 3: Decision

• Approved: Prescription can be filled, backdated if applicable
• Denied again: External review available (state insurance commissioner)

Step 4: External review (if still denied)

• Request external review through state
• Independent third-party reviews case
• Binding decision (30-60 days)

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Appeal Success Strategies

1. Comprehensive documentation:

• 6+ months diet/exercise records (not just 3)
• Multiple comorbidities documented
• Failed medication trials (metformin, orlistat, etc.)
• Cardiovascular risk scores

2. Medical necessity letter:

• Written by provider
• Explains why GLP-1 is medically necessary
• Cites clinical studies
• Addresses plan’s specific denial reason

3. Peer-to-peer review:

• Your provider speaks directly with insurance medical director
• Explains clinical reasoning
• Often most effective strategy
• Success rate: 50-70%

4. Employer intervention:

• If employer plan, ask HR to intervene
• Employers can override denials case-by-case
• Especially effective at smaller companies

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Out-of-Pocket Costs Without Insurance

Retail Prices (2025)

Monthly costs without insurance or assistance:

• Wegovy (semaglutide 2.4mg): $1,349/month
• Ozempic (semaglutide 1mg): $935/month
• Mounjaro (tirzepatide 5-15mg): $1,069/month
• Zepbound (tirzepatide 5-15mg): $1,059/month
• Saxenda (liraglutide 3mg): $1,430/month

Annual costs: $11,000-17,000

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Manufacturer Savings Programs

Wegovy Savings Card:

• Eligibility: Commercial insurance that doesn’t cover Wegovy
• Discount: As low as $0-550/month
• Duration: 13 months maximum
• Not for Medicare, Medicaid, or cash-pay patients
• Website: wegovy.com/savings-card

Ozempic Savings Card:

• Eligibility: Commercial insurance patients
• Discount: As low as $25/month for up to 24 months
• Covers up to $150 of copay per month
• Not for Medicare/Medicaid
• Website: ozempic.com/savings-card

Mounjaro Savings Card:

• Eligibility: Commercial insurance (even if denied)
• Discount: As low as $25/month
• Maximum savings: $575/month
• 12 fills maximum
• Website: mounjaro.com/savings-card

Zepbound Savings Card:

• Eligibility: Commercial insurance patients
• Discount: As low as $25/month for 2 months, then $550/month
• Not for Medicare/Medicaid
• Website: zepbound.com/savings-card

Caveat: These cards work ONLY if you have commercial insurance (even if insurance denies). Cash-pay patients don’t qualify.

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Patient Assistance Programs (PAPs)

Novo Nordisk Patient Assistance Program (Wegovy, Ozempic):

• Eligibility: Income <400% federal poverty level
  • Single: <$60,000/year
  • Family of 4: <$125,000/year
• Benefit: Free medication for 12 months
• Application: novocare.com/obesity/products/wegovy/pap.html

Eli Lilly Patient Assistance Program (Mounjaro, Zepbound):

• Eligibility: Income <400% FPL, uninsured or underinsured
• Benefit: Free medication
• Application: lillycares.com

Takes 2-4 weeks to process, provides 3-month supply at a time.

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Alternative Lower-Cost Options

1. Compounded Semaglutide (Telehealth):

• Cost: $199-399/month
• Providers: Hims, Ro, Henry Meds, Mochi Health
• Not FDA-approved (same ingredient, not FDA-reviewed)
• Quality concerns, but significantly cheaper
• Legal gray area

2. Saxenda (Older GLP-1):

• Retail: $1,430/month
• Less effective (5-10% weight loss vs 15-22%)
• Daily injection vs weekly
• Rarely worth the cost

3. Metformin (Off-Label):

• Cost: $4-30/month
• Weight loss: 2-5% (modest)
• For prediabetes/diabetes primarily
• Much cheaper, less effective

4. Orlistat (Alli, Xenical):

• Cost: $50-200/month
• Weight loss: 3-5%
• Side effects: Gastrointestinal issues
• OTC option (Alli)

5. International Pharmacies:

• Cost: $300-600/month
• Legal gray area (personal importation)
• Quality/authenticity concerns
• Not recommended

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Cost Comparison Summary

Annual Costs Scenarios

Best case (insurance coverage with copay):

• Monthly: $25-100
• Annual: $300-1,200

Manufacturer savings card (commercial insurance denial):

• Monthly: $25-550
• Annual: $300-6,600

Patient assistance program (low income):

• Monthly: $0
• Annual: $0 (if qualified)

Compounded semaglutide (telehealth):

• Monthly: $199-399
• Annual: $2,388-4,788

Cash pay retail (worst case):

• Monthly: $935-1,430
• Annual: $11,220-17,160

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Coverage Strategies

Strategy 1: Maximize Insurance Coverage

If your plan covers weight loss GLP-1s:

1. Gather 6 months of diet/exercise documentation
2. Get comorbidities diagnosed and documented
3. Have provider submit thorough prior authorization
4. Prepare for appeal if denied
5. Consider peer-to-peer review

Success rate: 60-80% with comprehensive documentation

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Strategy 2: Use Diabetes Indication (Off-Label)

If you have diabetes, prediabetes, or borderline A1C:

1. Check your A1C (need ≥5.7% for prediabetes)
2. Ask provider to prescribe Ozempic or Mounjaro for diabetes/prediabetes management
3. Weight loss is secondary benefit
4. 80-90% insurance coverage for diabetes indication

Success rate: 70-85% if legitimately have prediabetes/diabetes

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Strategy 3: Savings Cards + Commercial Insurance

If insurance denies but you have commercial insurance:

1. Get denial letter from insurance
2. Apply for manufacturer savings card
3. Reduces cost to $25-550/month
4. Duration: 12-13 months typically

Annual savings: $4,500-15,000 vs retail price

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Strategy 4: Patient Assistance Program

If low income (<$60K single, <$125K family):

1. Apply to manufacturer patient assistance program
2. Provide income documentation
3. Get free medication for 12 months
4. Reapply annually

Savings: $11,000-17,000/year

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Strategy 5: Compounded Semaglutide

If all else fails and budget is $200-400/month:

1. Use telehealth compounding platform (Hims, Ro, etc.)
2. Not FDA-approved but significantly cheaper
3. Be aware of quality/safety considerations

Savings: $6,000-12,000/year vs retail

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The Bottom Line

GLP-1 insurance coverage is complex and varies dramatically:

Best coverage scenarios:

1. Diabetes patient with any insurance: 80-90% coverage, $25-100/month
2. Live in mandate state with fully-insured plan: 70-90% coverage, $25-100/month
3. Employer plan that covers obesity: 25-40% of commercial plans, $25-100/month
4. Qualified for patient assistance: 100% free if income <$60K/$125K

Worst coverage scenarios:

1. Medicare beneficiary without diabetes: Zero coverage, $935-1,430/month
2. Medicaid in non-coverage state without diabetes: Zero coverage
3. Self-insured employer plan without coverage: Zero coverage
4. Individual plan with obesity exclusion: Zero coverage

Action steps:

1. Check your specific plan: Call insurance, review formulary
2. Verify state mandate status: See if your state requires coverage
3. Gather documentation: 6 months diet/exercise, comorbidities, labs
4. Try coverage first: Submit prior authorization
5. If denied: Apply for savings programs or patient assistance
6. Consider alternatives: Compounded semaglutide or off-label diabetes GLP-1s

The coverage landscape is rapidly evolving: More states passing mandates, more employers adding coverage, Medicare legislation pending. Check back every 6-12 months for updates.

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This guide provides general information about GLP-1 insurance coverage as of 2025. Coverage varies by plan, state, and individual circumstances. Consult your insurance provider and healthcare team for specific coverage determinations. Last updated: February 2025.