Why Isn’t My Weight Loss Medication Covered By Insurance?

One of the newer questions The Insurance People get asked frequently is, “Why isn’t my weight loss medication covered by my insurance plan?” 

News of the semaglutide medications, like Ozempic, Wegovy, and Mounjaro, has been everywhere, but the drugs are not accessible to everyone. So far, these medications have only been approved for insurance coverage for treatment of diabetes. The coveted side effect, weight loss, is what people have been paying huge sums for. And for a drug that needs to be continuously taken to see effects, paying out of pocket isn’t sustainable for most. 

So why are these new drugs so expensive right now? Primarily, it’s because one pharmaceutical company owns the patent until 2032. Because the company spent money up front to develop and trial the drug, and now owns the drug’s patent, the company is allowed to recoup as much cost as possible—that is, until other drug companies are able to use their formulation when their exclusive use is over.

With the current cost of these drugs being so high, combined with the fact that semaglutides are only effective if you continue to take them, it’s not surprising insurance companies don’t want to foot the bill indefinitely. It’s within their interests to keep the cost of medications they pay for down.

Currently, qualified plans that meet the standards of the Affordable Care Act do not offer weight loss medication coverage, and coverage of these medications isn’t expected to change while weight loss remains a secondary use. And more data is required to convince insurance companies the bill is worth paying. Because of its off-label popularity, the medications remain in a shortage for people with diabetes. The hardest part to swallow? Physicians still recommend people implement changes to their diet and exercise before considering prescribing semaglutides.