By: ARIEL J. WARDEN-JARRETT, MD, FAAFP
Many Americans are working hard to manage their weight and have set goals to lower their body mass index (BMI) to under 25. While this is a worthy goal, it can often feel like a challenging and sometimes frustrating journey. But the good news is that there are more resources and options available today than ever before to help patients achieve their weight management goals.
However, navigating the world of insurance coverage can add complexity to the process. Many patients experience disappointment when they go to the pharmacy to pick up a prescribed medication and discover that it is not covered or isn’t listed on their insurance’s drug formulary. They are often advised to contact their doctor’s office to request a prior authorization or a tier exemption. While it sounds simple, these processes can sometimes be more time-consuming and challenging than anticipated.
In each of our offices there are dedicated individuals working behind the scenes to get your medications covered. Sometimes each prior authorization may take significant time to complete and we appreciate your patience as we manage these requests.
It’s also important to understand that your employer plays a significant role in selecting your insurance benefits and choosing which medications are covered. Many patients may not realize this.
If a medication like Mounjaro or Ozempic, which is often prescribed for diabetes, isn’t covered for someone who isn’t diabetic, this is typically due to how the insurance policy is structured. If the medication doesn’t align with the required coverage criteria, even with a prior authorization, it may not be approved.
Additionally, starting in January 2025, some insurance plans will no longer cover medications like Zepbound or Wegovy for obesity alone, making it more challenging to get these treatments covered under certain plans.
So, what can you do if you’re facing these challenges?
- Talk to your employer: If you find that your medication is no longer covered or the coverage is limited, it may be helpful to ask your employer about the available options or if there’s anything that can be done to improve coverage.
- Work with your healthcare provider: Your doctor or healthcare team can help explore alternative treatment options and lifestyle modifications that may be beneficial in reaching your weight management goals. Together, you can find a plan that works for you.
- Check for manufacturer assistance programs: Many pharmaceutical companies offer discount programs or coupons to help offset the cost of medications. If you’re able to pay out-of-pocket, it might be worth exploring the cost of the medication without insurance, though be aware that these payments won’t apply toward your deductible.
- Advocate for change: If you’re facing difficulties with your insurance coverage, consider reaching out to your congressperson or state representatives to share your concerns. They are there to represent you, and they may be able to assist in advocating for changes or improvements in the system.
Remember, you’re not alone in this process, and we are all working together to find the best solutions for your health and well-being. Don’t get discouraged – there are resources available to help, and your healthcare team is here to support you every step of the way.
