It depends upon your plan. Every insurance coverage firm decides when it covers GLP-1 medicines for weight reduction, says Andres Sasson, MD, chief medical officer and cofounder of Lighthouse Weight Loss in Tampa, Florida. Most plans require you to fulfill sure standards, reminiscent of having a selected physique mass index (BMI) or a excessive BMI plus a associated well being situation like hypertension or excessive ldl cholesterol.
Over the previous few years, insurance coverage firms have added stricter protection necessities for GLP-1s used for weight reduction, whereas others have stopped masking these medicines altogether.
However these adjustments typically don’t have an effect on GLP-1s prescribed for different authorized well being circumstances, like sort 2 diabetes, which stay lined below most plans.
In line with Dr. Sasson, a part of the explanation that insurance coverage doesn’t cowl GLP-1s for weight administration has to do with price and timing. GLP-1 medicines can considerably enhance long-term well being by decreasing the chance of coronary heart illness, stroke, and different issues.
He explains that as a result of individuals usually change insurance policy each few years, one well being plan might pay for the medicine, however one other might even see the monetary financial savings from that particular person’s improved well being.
The way to Examine if Your Insurance coverage Covers GLP-1 Weight problems Drugs
Begin by reviewing your plan’s abstract of advantages and protection, which outlines lined providers, says Jennifer Brown, MD, a board-certified weight problems medication physician at MyObesityTeam. This doc is normally despatched to you originally of your enrollment yr, and you may usually discover it in your insurance coverage firm’s web site.
If you happen to’re excited about Wegovy, you may as well test protection and prices via its producer’s protection software.
However calling your insurance coverage firm is commonly the easiest way to test protection and eligibility necessities. Once you converse with an insurance coverage consultant, listed below are some inquiries to ask:
Does my plan cowl Wegovy or Zepbound for weight reduction?
What are the particular standards I want to fulfill for protection, reminiscent of BMI necessities and well being circumstances?
Is prior authorization required?
What documentation does my physician have to submit?
Do I have to strive different weight reduction strategies first?
What is going to my out-of-pocket price be if authorized?
How lengthy does the approval course of take?
The way to Submit a Prior Authorization Request
When you affirm that your plan covers GLP-1 medicines, the following step is assembly the necessities for approval. Dr. Brown explains that almost all insurers cowl GLP-1s for weight reduction if you meet one of many following standards:
BMI of 30 or larger
BMI of 27 or larger with at the very least one weight-related well being situation, reminiscent of hypertension or sort 2 diabetes.
Insurers might want proof that you just’ve tried to drop some weight via way of life adjustments earlier than turning to medicine, says Neika Small, a board-certified nurse practitioner and weight reduction knowledgeable at NuNava Well being. Because of this you’ll want to supply documentation of weight reduction efforts like weight-reduction plan adjustments, exercising, or behavior-based packages that weren’t profitable.
Small recommends having the next prepared when submitting a request for protection:
Your BMI and up to date weight historical past
Medical information displaying previous makes an attempt to drop some weight
Lab outcomes, like fasting glucose, hemoglobin A1C, and levels of cholesterol
A letter out of your healthcare supplier explaining why the prescribed medicine is medically vital
Your supplier’s workplace will normally deal with the prior authorization course of and ship these paperwork to your insurance coverage firm for assessment. If authorized, you’ll get a notification out of your insurer letting you know the way to fill your prescription. If denied, you’ve choices.
Insurance coverage Appeals
In case your insurance coverage denies protection for a GLP-1 weight problems medicine, step one is to name your well being plan and discover out why, says Brown. Some plans don’t cowl weight reduction medicines in any respect, and if that’s the case, sadly, an enchantment received’t change the result, she says.
In different conditions, the denial could also be as a result of sure necessities haven’t been met but. For instance, some insurers require you to finish a three-month, physician-supervised weight reduction program earlier than approving the medicine, says Brown. When you full these steps, your supplier can resubmit the prior authorization request.
For different sorts of denials, you may file an enchantment. To start the method:
Ask your supplier to assessment your information to ensure every thing that helps your want for the medicine is clearly documented, says Small.
Observe your insurer’s enchantment directions, that are normally included within the denial letter or on its web site.
Work along with your supplier to submit any further supporting documentation.
Your supplier may also request a peer-to-peer assessment, throughout which they converse straight with a healthcare reviewer or medical director out of your insurance coverage firm to make clear particulars and advocate on your case. “In my expertise with efficient appeals and peer-to-peer assessment instances, success was at all times a results of clear, concise documentation and persistence with the argument,” says Small.
She provides that when your supplier presents weight problems remedy as a part of managing a long-term well being situation and explains how the medicine can enhance blood sugar, ldl cholesterol, and weight over time, it helps strengthen your case for medical necessity.
Medicare and Medicaid
Medicare doesn’t cowl GLP-1 medicines once they’re prescribed particularly for weight reduction, says Brown. Federal legislation has lengthy prevented Medicare from masking weight reduction medicines.
In April 2025, federal officers reaffirmed this place, confirming that Medicare and Medicaid won’t cowl anti-obesity medicines, together with GLP-1s, via 2026.
Regardless of this choice, there’s an ongoing effort to alter this coverage, Brown says. The Deal with and Scale back Weight problems Act, which might enable Medicare Half D to cowl weight problems medicines authorized by the U.S. Meals and Drug Administration (FDA), was launched in 2023 however didn’t move. It was reintroduced in early 2025 and is at present making its manner via Congress.
That mentioned, Medicare might cowl sure GLP-1 medicine once they’re prescribed for different well being causes. Medicare Half D now consists of protection for semaglutide when it’s used to decrease the chance of coronary heart assault and stroke in adults with weight problems and present coronary heart illness.
Semaglutide was additionally authorized to deal with a liver situation often known as metabolic dysfunction-associated steatohepatitis in adults with average to superior liver scarring. As a result of these makes use of are thought-about medical, not beauty, they might qualify for protection. And when GLP-1s are prescribed for these different well being circumstances, weight reduction usually occurs as a facet impact of the remedy.
Medicaid protection varies by state. Small notes that some state packages cowl GLP-1 medicines for weight administration, whereas others don’t cowl any weight reduction medicine in any respect. “Others have a step remedy course of in place, by which cheaper weight reduction medicines must be tried first earlier than they’ll cowl GLP-1 medicines,” says Brown.
Protection guidelines can change relying on state funding and coverage updates, so it’s finest to test straight along with your state’s Medicaid program to see what’s lined and what standards apply.
