Understanding Weight Loss Treatment and Your Insurance in 2024

· The skinny: In addition to lifestyle changes, there are several medications used to help with weight loss. Tirzepatide (Zepbound) and Semaglutide (Wegovy) are two newer medications approved by the FDA for weight loss. They belong to a class of drugs known as GLP-1 receptor agonists.

· Will my insurance cover these medications?

It depends on the specific insurance plan and coverage you have. Some insurance plans do cover these medications, but they may have specific requirements or restrictions. 

· How do I know if I qualify?

To qualify for these medications, most insurance companies will consider coverage if you have a BMI (Body Mass Index) of 30 or higher or a BMI of 27 or higher with other comorbidities (other health conditions, such as high blood pressure or high cholesterol). Please note, unless you have a diagnosis of diabetes, the insurance company will most likely not cover Ozempic, Victoza, Saxenda, Trulicity, Bydureon, Rybelsus or other GLP-1 receptor agonists approved for diabetes only.

· Where do I start?

The first step is understanding the process above and to schedule an appointment to discuss the options with your healthcare provider. Prior to this appointment, it is important to do your homework. 

1. Be Prepared: After you have read the above, and you think you may qualify for medication, the next step is to check with your insurance plan if the medications are on their formulary. A formulary is a list of medications it covers, and tirzepatide and semaglutide may be included or not even if you qualify. To determine the coverage for these medications, what the copay or deductible requirements are, or if any prior authorization (PA) is needed, it is best for you to check with your insurance provider directly.

2. Practice Patience: After an appointment, if a medication is sent to the pharmacy, your medication will likely need prior authorization (PA). A PA is a process by which insurance companies require patients to obtain approval before they can receive certain medications. This is often done for weight loss medications to ensure proper usage, minimize potential risks, and control costs. The insurance company will review this information and decide on whether to approve coverage for the medication. It is important to note that PA requirements can be time-consuming and may cause delays in receiving the prescribed weight loss medication. Also note, if your insurance changes for any reason, this process must be restarted with your new insurance.

· What is next? After your appointment, your provider will submit a prescription to your pharmacy. The PA is usually initiated at that time, the request will typically include information such as your medical history, previous weight loss efforts, and any other relevant clinical information. The information is submitted by our staff in a timely manner. Once it is submitted to the insurance company, we wait on a determination (approved or denied).

· Finally, I can get my medication, right? Please understand that due to the high demand of these medications, even if your insurance approves the medication, there is a national shortage of supply. This is outside of our control and the responsibility is yours to find out which pharmacy has the medication in stock and have the medication transferred if needed. This applies to specific doses of medications. If your provider feels like you need a certain strength, please note ALL DOSE ADJUSTMENTS and NEW PRESCRIPTIONSare discussed in appointments, to ensure they are appropriate and to minimize unpleasant and unwanted side effects. 

We Support Your Journey!

At Golden Isles Family Healthcare your healthcare providers are aware and understand obesity is one of many chronic medical conditions and concur the approved weight loss medications are an overall safe, an effective tool for treatment (in addition to lifestyle modifications). Please be informed that there are alternative options, such as getting medications through a compounding pharmacy. These pharmacies specialize in creating customized medications by combining ingredients in specific doses, forms, and strengths that may not be commercially available. Our friends next door at NoFilter Aesthetics provide these services. You can learn more information through NoFilter Aesthetics by calling (912) 456-3952 or popping over to see them.

We ask for your understanding and patience as we try to navigate this process together, partnering with your insurance companies and pharmacies.