Why isn’t my weight loss drug covered by my health plan? And what is a Prior Authorization?

Why isn’t my weight loss drug covered by my health plan? And what is a Prior Authorization?

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These questions are major ones I am hearing from clients these days. I’m breaking this beastly topic down into smaller bite-size pieces to process with you.

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1. What are we talking about here?

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Weight loss drugs like Ozempic, Mounjaro, Wegovy and others are gaining traction in the healthcare industry. All of them are relatively new to the market, bringing hope to consumers and dollar signs to pharmaceutical manufacturers. There are several challenges with weight loss drugs, and the biggest challenge I see my clients face with them is the cost. These drugs are extremely pricey (some $500 - $1,200+ for a one-month dose). Many insurance plans won’t cover them unless the member has a type 2 diabetes diagnosis or if the coverage is a state-mandated benefit.

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2. Who SHOULD fit the bill for these high-cost drugs?

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These drugs are costly, and they are becoming more commonly prescribed. If you are a consumer, you may say the health insurance carrier should cover the cost of the drug. If you are an insurance carrier, you may say you cannot cover the cost of the drug when used solely for weight-loss as it could quickly drive up health plan costs due to high demand. There’s also the argument that the drug may cost a lot upfront, but the insurance carrier should cover it because if it helps someone achieve needed weight loss, it could lower future healthcare spend due to lower risk of hypertension, diabetes, etc. No matter which way you see it, it’s complicated and costly.

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3. What should you do if your weight loss drug is not covered by your health insurance plan?

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It may take a little research on your end, but you may have options.

·??????First, call your insurance carrier, and speak with their pharmacy department. Ask them to explain what their requirements are for covering your prescription drug. Do they require a diagnosis of type 2 diabetes? Do they require a certain blood sugar reading from your doctor’s office? Most (dare I say all) health insurance carriers now require a *Prior Authorization to cover these weight loss drugs (*more on PA’s below).

·??????Second, ask your doctor’s office to guide you through the approval process. The doctor’s office should know (or can find out for you) what your insurance carrier requires for approval.

·??????If the initial request for coverage is denied, your doctor can help you file an appeal. The appeal to the insurance company includes additional information/details related to your medical needs, your medical history, etc.

·??????Third, you can ask your insurance broker/benefits team for any guidance or escalation possible with your insurance carrier. This may not always bring the resolution you desire, but it can provide clarity if your prescription is being denied coverage by your health plan.

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*A Prior Authorization (AKA preauthorization, precertification, or prior approval) is something your doctor will need to obtain from your health insurance carrier in order for your medication to be covered by your health plan. Typically, the doctor will need to provide certain details to your insurance carrier showing the medication is medically necessary. For these weight loss drugs we are discussing today, the insurance carrier may require a diagnosis of type 2 diabetes and/or a specific blood sugar reading.

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Health insurance carriers may also require a Prior Authorization before certain prescriptions, medical procedures, and non-emergency services are covered.

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I am certain we are just at the beginning of this hot topic. I’d love to hear you weigh in on this topic in the comments section.

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#benefitsbeef #lonestarbenefits #deliveringexcellence #priorauthorization #ozempic #mounjaro #wegovy #weightloss #patientadvocacy