Anti-Obesity Medications – Are You Covered?

SUSAN MUSAL, NP | MEDICAL PROVIDER

Anti-obesity medications could be an important part of your health journey. Here are the tips, tools, and terms you should know as you talk to your primary medical provider and connect with your insurance and HR representative.

As someone who wants to live a long, happy, and full life, reaching and sustaining a healthy weight will undoubtedly be part of your wellness journey. Alongside a healthy, active lifestyle and other interventions and approaches, anti-obesity medications may be something to consider as you strive towards your ideal weight and body composition. But, like all prescriptions and procedures, a simple but important question needs to be answered.

Is it covered?

Before we talk about costs and insurance coverage, we should define what we mean when we say “anti-obesity medications.” These are FDA-approved pharmaceutical medications designed to help regulate your weight set point and ultimately, lose weight, Some of the most common prescriptions include…

• Semaglutide (Wegovy or Ozempic)
• Bupropion/Naltrexone (Contrave)
• Liraglutide (Saxenda)
• Tirzepatide (Mounjaro/Zepbound)
• Qsymia (Phentermine/Topiramate)

Note: Enara Health members have access to a team of specialists dedicated to obtaining prior authorizations for the anti-obesity medications listed above.) Before you start down a Google rabbit-hole about each of these products, we recommend you start by speaking first to your primary provider about this class of medications. Ask honest questions. Speak openly about your goals and your concerns. If your primary provider does recommend anti-obesity medications for you, it will help to know which medication in particular they plan to prescribe. Write it down and keep it handy. If you and your doctor decide to utilize anti-obesity medications as part of your treatment plan, you can avoid future frustrations and surprise bills by knowing exactly what is covered by your insurance.

Here are five ways to know with absolute certainty (again, no surprise bills!) if anti-obesity medications are covered by your insurance plan.

1. Call the pharmacy benefits phone number. On the back of most insurance cards is a phone number associated with pharmacy benefits. When connected, give the representative the exact name of the medication your doctor recommended. Be ready to ask questions like, “Do I need to meet a deductible before having the cost of this medication covered?” and “What, if any, is my copay for this medication?”
2. Check the insurance portal. If talking on the phone is not your preference, you can look up the anti-obesity medications within your insurance provider’s “Covered Medications” index on their website. Again, it will help to have the exact name of the medication your doctor recommends handy…after a few scrolls, all medication names start to look the same!
3. Check the specific medication. Many of the anti-obesity medications your primary provider will recommend will have pages of their websites designed to help potential patients find coverage options. For example…
   • Zepbound
   • Wegovy
   • Saxenda
   • Qsymia
   • Contrave
4. Connect with Human Resources. If you get your insurance through your employer, your HR representative can help you find out if anti-obesity medications are covered under your offered insurance plan. If these medications are not covered, you may decide to pass along letters and information about the science and research supporting the use of these medications in the treatment of obesity. This information may lead to coverage of anti-obesity medications in the future.
5. If you are an Enara Health member, utilize our team. Your Enara care team, which includes your Medical Provider, Nutrition Specialist and Exercise Specialist, will help you to decide whether anti-obesity medication is the right option for you, and which you might start with.  As mentioned above, we also employ a team of specialists dedicated to working with your insurance provider to obtain prior authorizations for some of the most frequently used anti-obesity medications.

A cheat sheet of insider terms.

Now, as you begin to research treatment options, you will likely come across a host of unfamiliar terms. For better or worse, these are commonly used in medical clinics and insurance offices but have less-than-obvious definitions.

• Formulary: A list of medications that are preferred on your insurance plan, often listed in terms called “Tiers” or “Preferred vs Nonpreferred”.
• Deductible: The amount of money you must pay before full coverage takes effect. These costs can often be in the range of hundreds to thousands of dollars.
• Co-pay/Co-insurance: The amount of money you must pay out-of-pocket for the prescription at the pharmacy check-out.
• Prior Authorization: Authorization completed by your medical provider to your insurance carrier which details why the medication is needed and how it would be beneficial to your care and overall health.
• Preferred vs Nonpreferred: As determined by your insurance plan, a Preferred medication is one for which your insurance provider will pay a higher amount. The Nonpreferred can still be prescribed, although your insurance company will pay less for it, which, of course, means you will ultimately pay more.
• Specialty Medications: These drugs are often high-cost prescription medications used to treat complex, chronic conditions. Specialty medications sometimes require special handling and administration. These are sometimes covered by medical insurance or prescription plans.
• Off-Label Use or Indications: This term is used for a medication that has been approved by the FDA for a specific purpose but is being prescribed for a different reason. Thorough research has been conducted on the alternative application, and has been determined to be effective and safe by that research. When prescribed, your provider must identify its use as specifically “off label.”
• Exclusion: An unfortunate circumstance in which your insurance provider determines they will not pay for this group of medications in any and all cases.
• Letter of Medical Necessity: A letter that is written on your behalf to your insurance company that offers supporting information as to why your provider believes the medication treatment should be covered.

At Enara Health, we are on a mission to reverse the current obesity epidemic and we believe anti-obesity medications are an important and valuable tool in this mission.

If you and your primary medical provider decide an anti-obesity medication is the right tool for your own wellness journey, you can use the information above to know if and how those medications are covered by your insurance. Every patient deserves to take control of their health with dignity and pride. This begins by being empowered with correct and actionable information as well as access to a full range of options, including anti-obesity medications. If you believe this class of medications could be a benefit to you, talk to your medical provider soon. If you’re interested in finding a care team, learn more about how Enara works with obesity medications to customize a weight loss plan for you. Medical Providers: If you would like to refer your patients to a medically guided weight loss protocol, learn more about our medical provider referral program. Clinics: If your clinic is looking to add obesity care to your services, check out our partner model.