Many individuals seeking to manage their weight explore various avenues, including medical interventions. Understanding insurance coverage for weight loss medications is crucial for making informed decisions. This article delves into the specifics of Buckeye insurance, particularly The Ohio State University Health Plan, regarding coverage for weight loss medications, providing clarity on eligibility, requirements, and changes in policy.
Buckeye Insurance and Medication Coverage: An Overview
Generally, Buckeye insurance covers drugs deemed medically necessary. The Pharmacy and Therapeutics Committee, a team of independent healthcare experts, reviews and approves the list of drugs covered, which is available in the List of Drugs (Formulary). This formulary can be accessed through a Drug Search Tool or a PDF document, offering a comprehensive list of covered drugs and any associated restrictions or limits. Drugs are listed by medical condition and alphabetically within the index for ease of navigation. It is important to note that not all drugs are included, and coverage can be subject to exclusions. If a drug is deemed unsafe by the Food and Drug Administration (FDA) or the drug's maker, it will be promptly removed from the list.
Understanding Generic and Brand Name Drugs
Buckeye insurance generally favors generic drugs, which are FDA-approved and considered as safe and effective as their brand-name counterparts. These generic drugs contain the same active ingredients, indications, dosages, safety profiles, and strengths as brand name drugs, but typically at a lower cost. Members can fill prescriptions at any network pharmacy. For specific questions about the list of drugs or to obtain the most recent version, members are encouraged to contact Member Services.
Specifics of GLP-1 Medication Coverage for Weight Loss
The Ohio State University Health Plan has specific guidelines regarding GLP-1 (glucagon-like peptide-1) medications. Starting January 1, 2026, GLP-1 medications will only be covered when prescribed for the treatment of type 2 diabetes; coverage for any other uses will be discontinued. However, coverage for certain weight-loss medications like Wegovy (semaglutide), Saxenda (liraglutide), and Zepbound (trizepatide) will continue through December 31, 2025, subject to specific requirements.
Requirements for GLP-1 Coverage Through 2025
To maintain coverage for GLP-1 medications for weight loss through December 31, 2025, participation in Omada, a virtual health program administered through Express Scripts’ EncircleRx, is required, along with meeting certain coverage criteria. A 30-day supply limit is in place for GLP-1 medications used for weight loss.
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The Omada Program and Enrollment
Once Omada enrollment is complete (regardless of approval or denial for the program itself), a healthcare provider can submit a Prior Authorization request for the desired GLP-1 weight-loss medication to Express Scripts. Active engagement in Omada is crucial to maintain coverage, defined as four weigh-ins and four app engagements per month. App engagements are flexible and can include completing lessons, communicating with a health coach, tracking meals, participating in peer group conversations, completing exercise goals, and other activities offered by Omada. Individuals who previously enrolled in Omada for Prevention may already be familiar with these activities. New enrollees will receive a scale and any additional necessary equipment based on their initial enrollment responses, and a coach will reach out to provide support.
Consequences of Not Meeting Requirements
If all requirements are not met, the Plan will not cover any portion of the cost of GLP-1 medications for weight loss.
BMI and Qualifying for Coverage in EncircleRx Weight Loss
Body mass index (BMI) is a key factor in determining eligibility for weight loss coverage. If an individual's BMI is between 27 and 31 and they have two weight-related issues, they may qualify for coverage in EncircleRx Weight Loss. Omada partners with Express Scripts to provide virtual programs offering support for various health conditions, including weight loss. The health coaches available through Omada are experts in weight-loss and obesity disease management, providing access to tools and resources to help manage weight and achieve additional health benefits.
Rationale Behind Coverage Changes
The decision to discontinue coverage for GLP-1 medications for weight loss (except when prescribed for type 2 diabetes) starting in 2026 was made after a thorough analysis. Continuing to cover these medications for weight loss was deemed unsustainable for all enrolled members who share in the total plan cost. Maintaining coverage would have required significantly raising costs for all employees. This change enables the university to minimize employee contribution increases and preserve other medical benefit coverage in 2026. Individuals currently using a GLP-1 medication for any indication other than type 2 diabetes should consult with their healthcare provider to explore alternative options.
Additional Weight Management Resources
The Ohio State University Health Plan offers additional weight management resources through Your Plan for Health (YP4H). These resources include a self-guided weight management BMI overview, general nutrition guidelines, optimal portion sizes, recommended exercise guidelines, and educational videos. Weight loss reduces the risk of chronic conditions like heart disease and diabetes.
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Cost Considerations for Medical Weight Loss Programs in Buckeye, AZ
In Buckeye, AZ, the cost of medical weight loss programs can vary significantly, ranging from approximately $500 per month to upwards of $1,000, depending on the specific services and plans provided. These comprehensive programs often include personalized consultations, tailored dietary guidance, medication management, supplements if appropriate, and ongoing monitoring. Initial consultations and evaluations typically involve separate fees, usually from around $100 to $300, depending on individual needs.
Factors Influencing the Cost of Weight Loss Programs
Several factors influence the cost of weight loss programs, including the treatment approach, length of the program, medical oversight, and an individual's health profile. If an individualized weight loss plan includes prescription medications, such as appetite suppressants or specialized weight loss injections, these can affect overall costs. Medication expenses may range from approximately $50 to several hundred dollars per month, depending on the type prescribed and insurance coverage. Some medically supervised weight loss services may be partially covered by insurance, particularly if obesity-related health conditions like diabetes, hypertension, or sleep apnea are present.
Inclusion of Weight Loss Medications in Program Fees
The inclusion of weight loss medications within a program fee can vary depending on the individualized treatment plan and the specific weight management program selected. Typically, comprehensive weight management packages include regular consultations with healthcare providers, personalized dietary guidance, lifestyle coaching, and ongoing medical supervision. Weight loss medications are often prescribed separately and filled through a pharmacy, with costs potentially covered fully or partially by insurance plans or requiring out-of-pocket payment.
Affordability of Group-Based vs. One-on-One Programs
Group-based programs are often more affordable due to their structure, utilizing shared resources such as supportive group sessions, educational workshops, and peer accountability. These group sessions allow healthcare providers to efficiently guide and support several patients simultaneously, lowering the cost per participant. Personalized medical weight loss programs include one-on-one consultations, individualized health assessments, and customized treatment strategies tailored specifically to each patient’s unique medical history and weight loss goals. While these personalized programs typically involve greater provider attention and specialized resources, the increased cost is often justified for patients requiring a more targeted and customized approach.
Impact of Weight Loss Goals on Program Costs
The overall cost depends on several factors, including how much weight an individual plans or needs to lose, their existing health conditions, and their personalized wellness objectives. Patients with significant weight loss goals may benefit from comprehensive, medically supervised programs that offer extended support, frequent consultations with experienced providers, nutritional counseling, customized meal plans, and ongoing health coaching. Such extensive services may involve higher overall investments but are carefully tailored for optimal results and better long-term health outcomes. Streamlined programs and services designed to meet objectives efficiently, potentially resulting in lower overall expenses may be available for those with more modest weight loss goals.
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Manufacturer Savings Programs
Pharmaceutical companies offer discounts for certain medications through self-pay savings programs.
Contact Information
For questions about benefit changes, individuals can contact HR Connection. For more information about medical weight loss programs, individuals can contact Centra Internal Medicine located at 23390 W Yuma Rd Suite 101B, Buckeye, AZ 85326, serving patients from Buckeye AZ, Liberty AZ, Westpark AZ, Goodyear AZ, Glendale AZ, and surrounding areas.
Disclaimer
Information provided is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment.
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