Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh, and you are listening to the Conquer Your Weight Podcast.

Announcer:
Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh.

Dr. Sarah Stombaugh:
If you have been trying to get your GLP medication like Wegovy or your Zepbound covered by insurance, and you are just running into one barrier after the next, that is what we are talking about today. How do you know if these medications are covered by insurance? What should you expect in terms of copay? Are there other requirements that you will have to meet? And then if all of that fails and you’re just thinking about the cash pay option, let’s talk about that as well. Because I think navigating the cost of these medications has been one of the biggest changes in the landscape over the last couple of years. This video will go live in February of 2026. And this is one of those videos that if you’re listening to in a few years, it’s probably going to be out of date. So if you are listening to it live or within the first couple of months that it premieres, I want you to share this with someone in your life, someone that you know has been taking these medications or maybe has had frustrations with their coverage. We are going to dive into all of the pieces and talk about all of the medications. We’re talking about Wegovy, we’re talking about Ozempic, we’re talking about Zepbound, we’re talking about Saxenda or Liraglutide and what you can expect because it has been crazy. So let’s talk about this. Insurance coverage. And before we talk about all the cash pay stuff, because you’re just like either forget it or you find out, okay, I do not have insurance coverage.

One of the biggest challenges is that the insurance coverage of these medications is not universal. This is something that I feel confident at some point in the future, this will not always be the case. But right now, coverage of medications for the treatment of weight, so including the GLP and the GLP GIP medications, so the Wegovy, the Zepbound, et cetera, these medications are not universally covered as part of our traditional health insurance. Now, one of the biggest challenges is that many of these medications are covered when we’re talking about the treatment of type 2 diabetes. And this is not pre-diabetes, this is not impaired fasting glucose or a little bit of elevated blood sugar in the morning. This is full-blown type 2 diabetes. And so this is a really big frustration. Patients get frustrated with this. As a physician, I get frustrated with this. You know, so often we look at someone who has prediabetes and we’re like, you would absolutely benefit from this medication, and no one’s going to argue with that except for your insurance company. So if you have type 2 diabetes, we’re not going to be specifically talking about that today. The coverage of these medications is quite a bit better for patients with type 2 diabetes. Traditionally, we’re thinking about medications like Ozempic and Mounjaro in that situation. But even then, there still may be some requirements, like you may have to take other medications first. Very commonly, you may need to do a trial of a medication called metformin and or sometimes additional medications as well. So different topic for a different day. But I say that to say if you do not have type 2 diabetes, no one has said you have diabetes, maybe they’ve said prediabetes, maybe they said you’re at risk for diabetes. But if you do not have type 2 diabetes, that is the insurance coverage that we are talking about today. So if you are looking to take these medications for the weight reduction indication, so traditionally that is a BMI of 27 or higher with a weight-related comorbidity. So that’s things like high blood pressure, high cholesterol, arthritis, pre-diabetes falls into that category, PCOS falls into that category. There may be other things like liver disease or thyroid disease or other conditions that may be associated with obesity. We know that many, many are.

Very rarely will I encounter someone who does not does not have something, even if it’s just the earliest signs of osteoarthritis in their knees, for example, that is going to meet that criteria for a related health condition or a comorbid health condition. So BMI of 27 or higher with a related health condition. And there’s that group of patients, there’s also a group of patients who have just a BMI of 30 or higher, regardless of their comorbid conditions. So if you meet either of those criteria, that’s where we are looking at, okay, do you have insurance coverage for that? And for that traditional weight criteria, one of the biggest challenges has been is that we do not have at this time, February of 2026, we do not have universal coverage of these medications. When we look at health insurance, and this is true when we’re talking about any commercial health insurance plan. So either you get insurance from your employer or you get insurance from the marketplace. Either way, you know, we’re talking about the Aetna and the Blue Cross BlueShield and United and Cigna and all of the health insurance plans. Even if you have a really, really good health insurance plan that covers most things, obesity or the management of weight health conditions is a carve-out area. So we have our traditional health insurance and that covers everything. That covers you have high blood pressure, you have a sinus infection, you have a pregnancy, you have cancer, you have a heart attack, you have a broken bone, like everything gets encompassed in that traditional health insurance.

And then there’s typically two carve-out areas. One is for fertility treatment, though that will be depending on your state. Some states do require that insurance plans cover that, but fertility treatment, like IVF or IUI, for example, may or may not be covered by insurance. And then separately, weight management is a carve-out area. So when a commercial insurance plan, so typically in the situation of an employer, an employer is working with an insurance broker or their HR is working with an insurance broker to determine, okay, what are the benefits for our employees? What is the insurance for our employees? When that broker goes out to get quotes, they might get a quote for a Blue Cross Blue Shield plan that either has weight coverage or does not have weight coverage. So it might be the exact same plan. And then you can add on the weight coverage piece. The challenge is, is the weight coverage piece is incredibly expensive. And so, particularly for smaller employers, and when I say smaller, I mean usually like less than a thousand employees. This is incredibly cost prohibitive for an organization to offer this to their employees. A lot of times it may be many hundreds of dollars a month per employee additional in order to cover that. And then when we think about large employers, because so many people may qualify for these medications because of the popularity of these medications, it is also expensive and it is becoming incredibly cost prohibitive for commercial insurers, for employers with their commercial insurance to offer this benefit.

So the way it stands right now in 2026 is that there is an opt-in or an opt-out of that insurance coverage for weight-related health conditions. So your employer, if they are opted in, great. We’ll still talk about there’s a process you have to go through. Rarely does it just get approved for you to take these medications. But if they are opted out, the biggest challenge is that there is nothing that I, as an experienced obesity medicine physician or any physician can do besides live, but there is nothing ethical that we can do, no truth that we can tell, no loophole that we can jump through. If they have opted out of insurance coverage for these medications, for the weight reduction indication, there is nothing that I can say, there’s nothing that I can do in order to get these medications covered. And trust me, I have tried. I have the patients who’ve been the perfect candidate. We are looking down the pike at prediabetes associated with obesity. And we’re like, this is the perfect candidate. Let’s prevent type 2 diabetes. Let’s help this person reverse their health condition before it turns into type 2 diabetes. And everyone agrees. I agree. The patient agrees. We’re so excited. It makes a lot of sense. And if the employer is opted out to that weight management indication, there’s nothing that we can do in order to get those medications covered. Now, there are still options, and the cash pay options are becoming pretty appealing. So if you’re in that situation, don’t just log off yet because there are some options that we can consider. But I do want to talk about the people who do have coverage.

As I mentioned just a moment ago, just because you have coverage does not mean that you will automatically get these medications covered. Typically, there’s something called a prior authorization that’s required. A prior authorization is a process that a physician or a prescriber will go through in order to get a medication covered for a patient. And that prior authorization process typically looks like, okay, we are showing that this patient is a candidate for medication. So we’re showing that they meet the BMI criteria. We’re giving chart notes, we’re giving their weights, we’re showing their other health conditions and notes and saying, okay, this patient has met these criteria. Now, the biggest challenge is it doesn’t just have to be those criteria. It could be at a baseline, but it may be other things as well. So very commonly we see things like patients are required to follow a calorie deficit diet for a period of time. A lot of times we’re talking about a six-month program or to be involved in regular exercise. A lot of times the number you hear thrown out is 150 minutes per week of exercise. And so the chart may need to reflect that this patient, for six months prior to trying to get medication approved, has been involved in a comprehensive weight management program that includes intensive lifestyle intervention with diet changes with a 500-calorie restriction. I’m making that, you know, I’m not making this up, and this is not what I necessarily require for my patients, but that the 500 calorie deficit per day, as well as 150 minutes of exercise per week, sometimes that exact language. So you may even send this to a prescriber and say, hey, have we, you know, I know I’ve been working on this for a while. We’ve been having trouble getting medications approved. That comprehensive lifestyle piece with a 500-calorie deficit, 150 minutes per week, sometimes that’s a golden language. And we need patients to have been involved in that for six months, for example, beforehand. So it’s a very common criteria.

They may also say things like, has the patient used other medications? So they may require something like step therapy, meaning that there are older medications for the treatment of weight, like Qsymia, like Contrave. These are older pills that are moderately effective and may still be a really good fit for the right individual. But have they used those medications in the past? Have they used those and found that those medications have been ineffective or not effective enough to help change some of their other, you know, let’s say they’ve maybe lost a couple of pounds, but they’re still have pretty significant high blood pressure, for example. Okay, well, we want to see more benefit from medication beyond what one of these older pills like Contrave or Qsymia could offer. So they may have step therapy requirements where you have to say, okay, this patient has used these other medications and they haven’t worked for them. Maybe there’s a very specific contraindication to a medication. So someone has a contraindication, you’re like, well, I can’t even try them on that medication because it would put them at risk of a severe complication. And so that could be documented and that’s very effective. But the prescriber will have to go through this prior authorization process. And typically from there, as long as you answer the questions correctly, as long as the patient does meet criteria, we’re going to see coverage for these medications. Now, there may also be requirements that medications like Saxenda, which is the older one’s daily GLP or Wegovy, are required before using Zepbound. So there may be things like that that come up. This is particularly true if you have CVS Caremarks. So patients with Aetna insurance, but a lot of Blue Cross Blue Shield plans will require this as well, where you’ve done Saxenda and or Wegovy before having the option to do Zepbound medication. So there may be some of those step therapy requirements, but if you meet those, typically we see, okay, the prior authorization gets approved.

Now, one of the biggest challenges that I run into then is that even when we have an approved prior authorization, that doesn’t mean that these medications will be affordable. So the patient has an approved prior authorization in hand. It says, okay, congratulations, your medication’s approved for the next six months or 12 months or whatever it is, those numbers can vary too. They go to their insurance or they go to their pharmacy rather, they go to pick up the medication and they’re told, okay, your copay is $1,000 or $1,200. And they’re like, what in the world? Why is this medication so expensive? I have insurance coverage, big air quotes there, because it doesn’t really seem like coverage if it’s $1,000 or $1,200 per month. So this sometimes comes up as well, where patients may have to meet deductibles before the medication is covered. And this can be really challenging. So depending if you’re an individual, if you’re in a family, what is your deductible? Is it $2,000, $5,000, $10,000? It may still be worthwhile to consider paying out of pocket for these medications, even though you have insurance coverage. And I hate even saying that, but I have multiple patients who are actually in that situation where we have decided, let’s just do the cash pay option because your family is unlikely to meet your deductible this year. And that has been their preference. Obviously, I’m not making the decision. I’m not going into my patient’s wallet to make that decision. That is their decision to make. But what can absolutely be the case is there may be a deductible that has to be met. It’s, you know, February. So over the last month or so, we’ve been getting a lot of these type of calls from our patients because this is often the case where a deductible may have to be met, that may be your traditional medical care deductible, there may be a separate pharmacy deductible that you have to meet in order to get those medications covered. So if that is a situation, my recommendation, you go to the pharmacy, they’re like, hey, it’s $1,000, it’s $1,200. You’re like, what the heck? I cannot afford that amount of money. Call the number on the back of your insurance card and say, hey, I got a prescription for Wegovy, I got a prescription for Zepbound, I have an approved prior authorization, but here I am standing at my CVS or Walgreens or whatever pharmacy, and they’re telling me it’s this much money. Can you explain to me why that is? And they will be able to explain to you what you have to meet in terms of deductibles.

So calling that number on the back of your insurance card is really the best way to get that information. So that can be one way that you figure that out. If you find out, okay, I do not have or I do have insurance coverage, but it basically doesn’t seem like I have insurance coverage because it’s so expensive. So when that is coming up, call that number on the back of your card. Now, if you do have a higher copay, one of the things that we often don’t talk about is that for Zepbound and Wegovy, so you’ve been prescribed these medications for the weight reduction indication, for Zepbound and Wegovy, they actually both have copay cards available. So this may be applicable to the person. It may not always be applicable in terms of deductibles, but it but it may be. So ask your pharmacy. You’re going there, like, hey, is there a copay card available? If you pull up your web browser and you just type in, hey, Wegovy coupon, Zepbound coupon, you’ll see typically two separate ones, one that’s a cash pay coupon and one that is for patients who have insurance coverage but can bring that deductible down that will bring off sometimes a couple of hundred dollars, but a couple of hundred dollars is a couple of hundred dollars. The copay in theory could be as low as $25 if it’s higher than that. But again, it’s only going to bring off a couple of hundred dollars there. But there are copay cards available. So don’t forget about those because I think they get sort of lost in, lost in the wayside. Now, as I was thinking about, okay, we’re calling the insurance company, we’re asking them, that could be really good to you to determine do I or do I not have coverage for this medication? So even going back to that person who’s like, well, do I have coverage? Do I not have coverage? How do I find out if my employer is opted in? Calling the number on the back of your card, or alternatively, going on your drug formulary online, specifically looking at Wegovy, specifically looking for Zepbound, that is going to give you good information. As we were talking about before, especially if you call, but even if you’re just looking online, you’re going to often see, hey, I have Ozempic coverage or hey, I have Mounjaro coverage. And that can be really exciting.

But again, if you do not have type 2 diabetes, you very likely do not actually have coverage for the medication because the prior authorization for those medications is going to require proof of your type 2 diabetes diagnosis. But looking at the insurance formulary, calling the number on your back of the card is a good way to even figure that out as you’re getting this process started or before you go even go in to meet with your physician. Now, let’s say you find out either A, I do not have coverage for these at all, or B, my coverage is so wild. Maybe I have such a high deductible to meet that I want to think about cash pay options. Now, a lot of people who have Medicare are going to be in this boat. We do anticipate that Medicare is going to have coverage for these medications for the weight reduction indication starting in the spring, like April or May of 2026. I’m holding my breath that that will actually happen, but it is anticipated that Medicare will have coverage of those medications for those indications starting later this spring. But right now, as of February, there is not yet coverage for that. So if you are a Medicare patient and you’re looking to get coverage, you may be able to get it under a separate medical diagnosis. So Zepbound is covered for the treatment of sleep apnea. Wegovy is covered for the treatment of cardiovascular risk reduction as well, risk reduction as well as for liver disease. So you may be able to get it covered for those indications. But if you were talking about it for the traditional weight reduction indication, again, even if it’s significant weight that you’re talking about, even if it’s prediabetes and other conditions, that is not going to meet criteria at this time. And so people who fall into that boat, we are anticipating coverage of that in the spring. But right now, we’re looking at cash pay options. Medicaid is going to be very state-by-state dependent. So if you have Medicaid, it is best to have a conversation with a local physician about what does this mean for me? Do I or do I not have coverage? Because some states do and some states do not. But that is quite variable and will depend on your states. We’re not going to dive into that today. But if you are talking about the cash pay option, so this is relevant for patients with Medicare right now who are looking at the weight reduction medication. And this is relevant for patients who have commercial insurance but do not have weight management medications covered, as well as for patients who have coverage, but maybe the cost is unattainable.

Now we are thinking about cash pay options, and there’s a lot of options that may be available to you. So let’s start with some of the oldies but goodies. Saxenda, this is a medication I think does not get enough press. It is a once-a-day GLP receptor. The big news about this medication is the diabetes version of it, Victoza, went generic last year. So generic liraglutide. And the cost of this medication starts at $83 per month, depending on the dose that you’re on. So in the starting dose of medication, it’s $83 per month. As your dose goes up though, it does basically double or triple. So the 0.6 milligrams is $83, the $1.2 milligrams is what’s $166. And then the 1.8 milligrams, the highest dose available in that generic liraglutide pen is basically $250. So that’s a pretty decent option, especially for someone who has less significant metabolic disease or less significant weight to lose. However, it is a much less potent GLP. So if you’re talking about chronic and significant weight or metabolic disease that you’ve been dealing with, Wegovy and Zepbound are going to be your best options. So let’s talk about Wegovy because Wegovy is available in a few different forms. Wegovy is a semaglutide product. So Ozempic and Wegovy are the exact same medication. Recently, last month, Wegovy was also released as a pill. So we have injections as Ozempic and Wegovy injection. We have the pill as the Wegovy pill, and these prices are intermediate. So the Ozempic medication is $199 for the lower doses of medication, the 0.25, the 0.5, the 1, it is $499 for the top dose of medication for that two milligram dose of Ozempic. Now, the reason the Ozempic is a diabetes medication, but the reason that I mentioned that is it’s a multi-dose pen. So sometimes we are able to deliver a partial dose of medication using the Ozempic medication. So we’ll have someone get a two-milligram pen, for example, that’s $500 a month or $499 a month, and then they can divide up to take a partial dose of medication. So that can be a pretty cost-effective option depending on where you’re at with your Ozempic dosing. Wegovy injection starts at $199 for the lower doses of medication for the first two months, then goes up to $349 per month for all doses of Wegovy for the pen. And now for the pill, we see it starting at 149 for the lower two doses, 199 for that second dose after April. So after April, we’re gonna see that price jump up. And then it is 299 for the top two doses of that medication. Then we look at Zepbound. Zepbound does have the pens as well as the vials program. The pens are available at $499 per month, regardless of the dose. So if you do not want to be drawing it up from a vial, you don’t want to be injecting it, that’s a really great option. If you are open to the vials though, they are cheaper at the starting doses: $299 for the $2.5, $3.99 for the five, and $449 for the 7.5 milligram and higher. You do have to refill those every 45 days in order to maintain that three or excuse me, 449 pricing. And so you want to make sure that you are doing that so your price does not jump up because the prices will jump up really significantly if you do not regularly refill that medication. That is to keep people from splitting the doses of that medication. So those are your cash pay options and they may be decent options.

The best thing for you to do is connect with a board-certified obesity medicine physician. If you are in Illinois, Tennessee, or Virginia, I would be so happy to see you as a patient in my medical practice. If you are outside one of those states, please still feel free to reach out. I’m always happy to connect you with someone else I know in this space, or for you, you know, take a peek at the American Board of Obesity Medicine so that you can find an obesity medicine doctor by you. Now, if you are starting a GLP medication and looking for support, I want you to check out our GLP guide. It is an online video program with answers to all the questions that you may have about your GLP medication. We talk about side effects, we talk about travel, we talk about how to inject, we talk about cost and coverage, all of this stuff, everything that you need to know is right there in one place. So check that out at SarahStombaughmd.com/glp. Thanks for joining us this week. I’ll see you all next time.