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:
A story that we hear and experience in our clinic all too frequently is the patient who has started a GLP medication, they had insurance coverage for it, perhaps a pretty decent copay that they were paying every month to get their medication covered, and then all of a sudden something changes and their medication is no longer covered by their insurance. And this can cause so much anguish and grief and frustration. And if you are in that situation, what we are going to talk about today is everything that you should understand about the insurance coverage process for these medications, and then how you can help understand in the situation you are in, is there still a route to coverage? Because sometimes the answer is yes. And if not, is there another alternative or what are the other paths that I can pursue? I want you to know that I am here to support you so that you can have success with your weight long-term.

And if you’ve been taking a GLP medication, what that looks like likely is also what does it look like for long-term coverage of that medication. So let’s talk a little bit about the insurance coverage as it stands. At the time that I’m recording this, it’s the fall of 2026. And at this time, weight management medications are opt-in or opt-out. Insurance companies do not have to cover these medications. And I’m saying insurance companies, but I actually mean employer. So the way traditional commercial insurance works in our country is that it is predominantly employer based. So people who work for a large enough employer, their employer will have negotiated with any of the large commercial insurance companies. Maybe it’s Aetna, it’s United, it’s Blue Cross Blue Shield, it’s Cigna, whatever it is, they have negotiated a plan. And as they’re going through and their HR department is working with an insurance broker to determine the plan for their company, they have the ability to opt in to the coverage of weight management, treatment and medications or to opt out of that.

Now, it’s not as simple as just like, oh sure, we should provide that benefit for our employees. A lot of times this is an incredibly expensive benefit to add on, and so it can be cost prohibitive for especially small employers to be able to offer this benefit with the way things stand right now. Now we’ve seen a lot changing in the world of coverage. It was just this summer that we saw the rollout of the Medicare GLP Bridge program. So eligible Medicare beneficiaries can now access GLP medications at least for the next 18 months. So even that is a temporary plan. But what is exciting is we’re starting to see more conversation around it. And I feel very confident that there will be a point in the future where obesity management medications are the standard medical benefit and there’s none of this like opt-in, opt out, do I have coverage, do I not have coverage?

So at this point, even if you have really good insurance coverage, otherwise maybe you have a PPO plan or whatever is going on, you’re like, Hey, I have really good insurance. If your employer has opted out of the coverage of obesity management medications, there is nothing I or any obesity medicine physician or any prescriber for that standpoint, there’s nothing that I can say or do in order to get that medication covered. You could be the most appropriate candidate for that medication. You could have no contraindications. You could have tried all of the lifestyle interventions. You could be the perfect candidate for the medication and your insurance company will still say no because it’s not part of the benefit. And so it becomes very frustrating because in this way it feels like insurance is dictating medical decision making. And a lot of us feel like that is the case in these situations.

And like I said, it doesn’t matter what I say, it doesn’t matter how appropriate it is. In those situations when the employer is opted out, there is no route to coverage. Now for Medicaid, this is very state specific. If you do or do not have coverage, even if you do have coverage, very commonly there’s specific criteria that you have to follow. We’re not going to address that in today’s episode. For Medicare, we do have a few episodes about the Medicare GLP Bridge program. Make sure to check that out because it is exciting that we do have coverage for eligible Medicare beneficiaries. But for those with commercial insurance, let’s say you’ve had medication coverage and now you don’t, let’s talk about what to do and how to manage that. Now, one thing a lot of times as I’m having this conversation with patients is we’re talking even from the very beginning of your journey about what long-term could look like.

Now, part of it just needs to play out as it does, but we want to make sure if something changes, like if you didn’t have coverage, would you be able to continue the medication? Would you be able to pay out of pocket for the medication? Are there other options that we could consider? So let’s say you’ve just got that medication denial or you go to the pharmacy and they say, oh, it’s going to be $1,300 and you’re like, what do you mean? Last month I paid $50. Why would it possibly be $1,300 this time? Here’s a couple of things I want you to explore. Now there’s a process called prior authorization, which means that your prescriber has to basically share with the insurance company information that shows that you are an ideal candidate for these medications. Now the coverage can vary, but if we’re talking about these medications for the purpose of weight reduction, a lot of times the coverage is for patients who have a BMI of 30 or higher or those who have a BMI of 27 or higher with a weight-related comorbidity.

So let’s say your doctor did a prior authorization, your starting BMI was let’s say 35, you’ve been taking the medication, that prior authorization is approved for a period of time, and that can range anywhere from three months to 12 months in my experience. So maybe you have an expired prior authorization and so the pharmacy goes to check the insurance benefits, say, do you have coverage? If your prior authorization has expired, no big deal. You don’t want to go pick up your medication today. If you pay $1,300 for your medication, just kiss that money goodbye because you were never going to be reimbursed for it. So do not pay that money unless you’re okay paying that money for long-term. Walk away from the pharmacy, call your insurance, ask them if you still have an active prior authorization. If it’s expired, you can call your prescriber or send them a message because a lot of times it may just be a prior authorization renewal that is required.

Now, one really important caveat here is that let’s say we had that example of starting out BMI of 35. Let’s say you’ve had an approved prior authorization for a year, you’ve been doing really well, your BMI is now 26. When your prescriber fills out the renewal prior authorization, they should continue to use your initial BMI, your BMI at the time that you started the GLP medication in order to seek approval for that medicine. So they should not put in your new BMI of 26 because I’m telling you right now it will be denied. They’re not digging through these prior authorizations are approved by AI bots. There is not someone who’s personally looking at everything and saying, oh, she deserves coverage or he doesn’t or oh, it makes sense because they’ve lost weight. You need to use the starting BMI code is completely appropriate and acceptable way to do this.

And so we also want to make sure, let’s say you get a prior authorization denial, was a denial appropriate? So they’ve done a prior authorization, maybe they included incorrect or incomplete information. It may be appropriate to go through the appeals process. Now, actually as a patient, you could be the one to do the appeal or your prescriber could be the one to do that. So you’ll want to make sure to have a conversation with them. One of the best tools you can also do, and I’m so sorry to even say it, but is to pick up your insurance card, call the number on the back of the insurance card and ask them to explain to you what is going on. Sometimes we see other things coming up like drug formulary changes. So very commonly last year, for example, we saw that Zepbound was a preferred agent on a lot of formularies, but then it became off formulary and Wegovy became the preferred agent.

So there were many patients for whom had Zepbound coverage and then they had to switch to the Wegovy medication in order to continue using medications. So sometimes we are able to make drug switches to a similar type of medication, which can be incredibly still valuable for the patient. And then if they don’t do well, we can ask for an appeal and say, “Hey, this is why we still need to continue that original medication.” And we generally have really good success continuing the medications if that is the case. Now, sometimes what does happen is the employer actually changes their opt-in or opt-out coverage. So previously they covered it and then they realize, oh my gosh, we cannot afford this expense because so many of our patients are using medications for the treatment of obesity and they actually opt out for a future year. So January one is always my least favorite time of the year because we get inundated with messages from our patients that their employers, even they have the same employer, they have the same insurance, they don’t feel like anything’s changed, but the new benefits will often take place in the new year.

So it’s very common that we’re getting a lot of phone calls then. But you pick up the phone, call the number on the back of your insurance card, and that can be an incredibly helpful tool. So these are some of the things I want you to be aware of. Now, let’s say you just don’t have coverage and you’re like, “Well, shoot, what do I do from here moving forward?” A couple of different options we can consider. So one, you can pay out of pocket for medications. I recognize that that’s not in the budget for everyone, but generally that will look like anything from $149 per month on the low end of some of the oral GLP medications to other medications in the 350 to $450 range for medications like Wegovy or Zepbound. So that is a per month cost that can be pretty expensive, but it may be something that you’re able to make room for in your budget.

And so there are patients for whom they decide to make that decision. Certainly there are other patients who decide to go another medication route, whether that means looking at compounded medications or looking at non – GLP medications. One of the things that I often remind people is that before we had the GLPs, we had some other medications available as well, and many of those are still available as much less expensive alternatives. So medications like Qsymia, which is a combination of phentermine and topiramate, medications like Contrave, which is a combination of bupropion and naltrexone, as well as older medications like Saxenda, which is a once per day GLP medication, liraglutide. And liraglutide actually went generic about two years ago, so we’re often able to access that medication for anywhere from 80 to $250 depending on the dose of medication. So I want you to know if you’ve lost coverage, there is hope.

First, we have to figure out what is going on. Maybe you haven’t even lost coverage, but if you have, what is the reason why and is there anything we can do to resubmit or appeal that coverage option? And then if not, what are the alternative options, whether it’s cash pay or whether it’s considering another medication? There’s a lot of tools that we have in our toolbox. One of the benefits of seeing someone who is a board certified obesity medicine physician is this is what we do day in and day out. You hear so much about the GLP medications like Ozempic, Wegovy, Zepbound, Mounjaro, and these are awesome medications. They have totally changed the landscape of how we think about and treat obesity as a disease process. And there are so many other options that we can do both with lifestyle intervention as well as other medications, and you may be a good candidate for those other options.

If you are interested in working with me, I see patients in Charlottesville, Virginia in person and throughout the states of Illinois, Tennessee, and Virginia by telemedicine. You can learn more at www.sarahstombaughmd.com. Thanks for joining me for today’s episode. Please like, subscribe, share this with someone. If you’ve heard someone in your life recently complaining about losing insurance coverage, definitely make sure to send them this episode. We’ll see you all next week.