How to Get Your Health Insurance to Cover Ozempic and Other Drugs Used for Weight Loss

If you want to take one of the buzzy drugs like Ozempic or Wegovy to lose weight, the toughest part may be finding a way to pay for it.

Insurers and employers, fearing the cost of medications that list for $900 or more a month, often put up hurdles when patients seek access to one of the drugs to slim down. Yet there are ways to get your health plan to pay for your prescription, if you qualify - and some alternatives if you don’t.

“You’ve got to come with information, or it’s too easy for them to say, ‘No, goodbye,’ ” said Carrie Boswell, who in February was able to get her insurance plan to start covering her prescription for Wegovy, a sister drug to Ozempic.

After researching the drugs and her plan’s requirements, Ms. Boswell wrote a long note to her doctor that included her family history of diabetes and congestive heart failure. Under the definition used by doctors, she qualified as obese, and she aimed to lose about 60 pounds using the drug. She also documented that she had already tried two other weight-loss medications, a condition her insurer required before it would approve Wegovy.

“The more that you show you know, the more seriously you’re taken, so it’s not just something you saw on TikTok today,” said Ms. Boswell, 41, a federal employee who lives near Washington, D.C.

Demand for Ozempic, made by Novo Nordisk, has exploded amid social-media traffic and celebrity testimonials about its power to melt off pounds. The Food and Drug Administration approved the drug to lower blood sugar in people with Type 2 diabetes. Wegovy, which has the same active ingredient, was approved specifically for weight loss.

Another drug, Mounjaro from Eli Lilly, also got the FDA nod for diabetes. Testing has found it is also effective for weight loss, and it is expected to get the agency’s signoff for the use.

Doctors and other experts recommended the following steps for people seeking to get insurance coverage for Ozempic, Mounjaro or Wegovy.

Talk with a doctor first

First, you must see a doctor to find out if one of the drugs is clinically appropriate for you. The medicines can have significant side effects. Doctors say patients should work closely with a physician to understand the risks and monitor treatment.

Patients may want to seek out an obesity specialist, who can help create a broader program and likely knows how to navigate the insurance issues. You can search for one here.

If your physician does feel you are a good fit for one of the drugs, you can start to seek coverage by checking if your plan covers drugs for weight loss. Many don’t, including Medicare.

Weight loss has often been considered a “cosmetic” category, but this is starting to change as doctors increasingly view obesity as a medical condition that requires treatment. (You also might want to check on coverage of weight-loss drugs before selecting your health plan for next year.)

Novo Nordisk estimates about 40 million Americans who are overweight or obese have coverage, and the company offers an online tool to help you figure out if your plan includes Wegovy. You should still double check your plan’s policies. You can call the insurer, or look in the formulary, which is the list of covered drugs. This should typically be accessible in the insurer’s online portal.

Be specific with your health plan

If your plan covers drugs for weight loss, it might include Wegovy but not Ozempic and Mounjaro in that category. They aren’t FDA-approved for weight loss, so they often aren’t covered for that use.

Your doctor will probably need to seek authorization from the insurer or your health plan’s pharmacy-benefit manager to get your Wegovy prescription covered. Sometimes you can find the rules for approval online, as with these for UnitedHealth Group’s UnitedHealthcare, CVS Health’s Aetna and Cigna Group.

Diana Thiara, medical director of the University of California, San Francisco’s Medical Weight Management Clinic, advises doctors and patients to be as specific as possible in making their case for coverage. “If they say no, ask why,” she says - and try again.

Many plans require that patients have a body-mass index of at least 30 to qualify for Wegovy, or a BMI of 27 along with at least one related health condition such as high blood pressure. Those are the characteristics of patients who were treated in studies used to prove the drug worked. You can calculate your own BMI online.

“Sometimes you don’t even need prior authorization, if someone has diabetes,” says Lydia Alexander, president-elect of the Obesity Medicine Association and chief medical officer for Enara Health, an obesity treatment company.

If you don’t have diabetes, though, insurers may refuse to cover Ozempic or Mounjaro purely for an “off-label” use such as weight loss.

If you don’t have diabetes, and your plan doesn’t cover weight-loss medications, you’re likely facing an uphill battle. Many state Medicaid programs don’t cover drugs for weight loss. Among private plans, the approach varies, but the types of coverage bought by individuals and small businesses often don’t include medications for obesity.

Some patients and their doctors have petitioned employers to change their policies or make an exception. Novo Nordisk offers a form letter you can use. The company said it offers the letter because employer opt-in is key to expanding coverage.

You could face significant costs

Patients who do get an insurance plan to cover Wegovy, Ozempic or Mounjaro may find they face a big out-of-pocket charge. An analysis by KFF, a health-research nonprofit, found the average patient charge for a month of treatment on Ozempic or one of its sister drugs was $66 in 2021, but doctors say they sometimes see plans forcing patients to pay a percentage of the drugs’ cost, known as coinsurance, which can be hundreds of dollars.

For patients who can’t afford the fee, or aren’t able to get their insurer to pay at all, the drug companies sometimes offer help, though it’s typically limited. For patients whose insurance plans cover Wegovy, Novo Nordisk provides assistance that can reduce their out-of-pocket costs to as little as zero per 28-day supply, with a maximum benefit of $225.

For patients who don’t have insurance coverage for Wegovy, Novo Nordisk provides a discount of $500 off the full retail price. The $500 discount is good for up to 12 refills of a 28-day supply.

Lilly provides a savings card for commercially insured patients taking Mounjaro for Type 2 diabetes. If Mounjaro is covered, Lilly can reduce a patient’s out-of-pocket costs to as little as $25 per prescription.

But if a patient’s insurance plan doesn’t cover Mounjaro, Lilly has capped its assistance at $500 a month. That means the patient is responsible for the rest, which can exceed $500.

People who secure insurance payment for a weight-loss prescription should also remember it’s just the start of a continuing process. After several months on the drug, plans may require patients to hit a milestone before getting further refills. Often, patients must lose at least 5% of their pretreatment body weight. If they haven’t, their next prescription might not be covered, potentially halting treatment.

If patients lose enough weight, the insurer might decide they no longer qualify for treatment with the drug, raising the risk they will regain the pounds. Doctors say that in that situation, they would appeal the decision.

Articles in this section

Talk with a doctor first

Be specific with your health plan

You could face significant costs

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Articles in this section

Talk with a doctor first

Be specific with your health plan

You could face significant costs

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