Obesity, defined as having a Body Mass Index (BMI) of 30 or higher, and being overweight, defined as having a BMI of 25 or higher, are significant health concerns. BMI, calculated as a person’s weight in kilograms divided by the square of height in meters, is often used to screen for weight categories that may lead to health problems. Addressing weight issues often involves lifestyle and behavior changes, including prioritizing healthy eating and physical activity. Factors such as height, genes, metabolism, behavior, and environment can all influence your weight. It's essential to consult with a doctor to determine the best course of action if you're experiencing weight problems.
General Approaches to Weight Loss
Treating obesity requires lifestyle and behavior changes that include prioritizing healthy eating and physical activity. The Centers for Disease Control and Prevention (CDC) recommends balancing diet and exercise to lose and maintain weight. This means that the calories you get from food and drink should be balanced with the calories you use being physically active. Weight loss and weight maintenance are about shifting behavior or lifestyle habits for the long term. Work with your doctor and care team on a healthy eating plan that will help you get the right number of calories you need from your diet. Though calories aren’t the only way to determine a food’s nutrition, tracking them can be a good starting point on your weight loss journey.
Losing weight at a gradual pace of about 1-2 pounds per week is ideal if you want to be successful at keeping the weight off in the long term. Everyone has different nutritional needs. Eating healthy should be paired with physical activity. For overall health, aim for at least 30 minutes of moderate physical activity most days of the week. To manage weight, you can increase the time to 60 minutes. Keep in mind that common activities - like walking up and down stairs or pushing a stroller - can count toward physical activity. Once you’ve achieved a healthy weight, it’s important to continue eating healthy and exercising regularly to maintain your weight for the long term.
Practical Strategies for Weight Management
Writing down what you eat and how much you exercise daily can keep you accountable to weight loss or weight maintenance goals. The CDC has put out daily calorie recommendations for people to maintain their weight based on age, gender, and activity level. Make a habit of eating foods that have a high in nutritional value. Physical activity should remain an important part of your routine as well.
Here are some apps that provide free or low-cost at-home workouts:
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- Strava: If you enjoy being outdoors, Strava is a great way to track your runs, walks, and bikes. The app also lets you follow friends, so you can keep each out accountable on your workouts.
- Nike Training Club: The Nike Training Club app offers a library of at-home workouts. Users can filter by type of workout - from yoga to HIIT classes - as well as time and equipment available.
- ClassPass: Available for a monthly fee, ClassPass offers access to both in-person gym workouts and at-home virtual classes.
With more than 2,700 locations across the country, the YMCA is also a great community fitness resource.
The Role of Support Systems and Communication
A weight loss journey can be difficult, especially if you are not seeing results as quickly as you would like. But, be mindful that even small steps can have big health benefits. The CDC says that weight loss of just 5 to 10 percent of your total body weight can lead to improvements in blood pressure, blood cholesterol, and blood sugars. Talking to friends and family and creating an accountability system may help to make the journey easier. For example, if a friend is hosting a party, you could check in with them before the event to ask about the food options and then plan accordingly. Friends and family can also be there to observe your lifestyle changes and make sure that you are losing weight in a healthy way. It might be helpful to talk with a mental health professional or others with obesity who understand how you feel.
Communicating your needs can help you to stay on your weight loss journey without sacrificing fun or social events. The National Heart, Lung, and Blood Institute has a list of tips for how to eat healthy when dining out. For example, consider asking if the restaurant can serve fat-free milk rather than whole milk; or ask for salad dressing and any sauce on a main course to be put on the side. It’s also important to communicate any struggles you may be having. People who are successful in their weight loss journey often rely on support from others to help them through challenging periods. It can also be helpful to go through weight loss with a partner who is also trying to lose weight to help stay motivated.
EmblemHealth Coverage Policies
General Information
EmblemHealth offers special health programs for eligible members and a library of information on many health topics to help you take care of yourself. Caring for your mental health is just as important as caring for your physical health. If you need help right away, see our resources to get assistance now. Behavioral health or substance use issues can vary widely. From depression to anxiety to the misuse of alcohol, medication or other substances. What they all have in common is the ability to affect quality of life. No matter what you or your family are dealing with, there are people who can help through the Emblem Behavioral Health Services Program.
EmblemHealth covers you for medicines used to treat substance-use disorders. This includes medicines usually prescribed for opioid addiction and dependence.
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Updates and Changes
As of Jan. 31, 2024, EmblemHealth began covering crowns and root canals in certain circumstances for Medicaid and Health and Recovery Plan (HARP) members. As of Jan. 1, 2024, undocumented noncitizens who are age 65 and over can join EmblemHealth’s Medicaid Managed Care plan. Previously, they were only able to receive emergency medical services by using their Medicaid card. Now, they can receive comprehensive health care services provided by EmblemHealth. Starting March 1, 2024, EmblemHealth will cover the Mobile Crisis Telephonic Triage and Response service for Medicaid members younger than 21. This service is already available to members 21 years of age and older. Members and their family can call 988 and talk to a professional about a crisis, get support, and be connected to other services when needed.
GLP-1 Drugs and Weight Loss
GLP-1 drugs, such as Ozempic and Mounjaro, are approved for the treatment of Type 2 diabetes and can be an important tool in treating diabetic members. For most GLP-1 drugs, members should have a Type 2 diabetes diagnosis in their medical record to be prescribed these drugs. This diagnosis should also be entered when requesting preauthorization from Express Scripts. We recommend sending your members for an A1C screening when appropriate to make sure the medication is necessary.
EmblemHealth and ConnectiCare do not cover all GLP-1 drugs for off-label use such as weight loss. Over the past year, drug companies have been heavily marketing GLP-1 drugs for weight loss benefits. This increased demand is causing drug shortages.
Real-World Impact on Coverage
Sarah Kalemkerian, a school administrator, found success with Zepbound, a GLP-1 drug, after her health insurance through the city covered it. However, she recently found out from EmblemHealth that she will lose coverage for Zepbound next year, making it unaffordable for her. Kalemkerian is one of nearly 1,000 city workers and their dependents who started on weight-loss drugs like Zepbound or Wegovy after they were added to a list of medications covered under an optional prescription rider for one of the city’s health plans earlier this year, according to EmblemHealth.
Liz Garcia, a spokesperson for the city, said the drugs were added in error, and keeping them on the list of covered medications could drastically increase health care premiums for employees. She added that the city will continue covering GLP-1 drugs for patients who use them to treat diabetes, but not weight loss.
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Employer Perspectives
The change in coverage comes at a time when interest in expensive GLP-1 drugs for weight loss is skyrocketing, and employers, Medicare, and other insurance providers are grappling with how to respond. Medicare, the federal insurance program for older adults, has long been banned from covering weight-loss drugs. But there’s a growing body of evidence that GLP-1 drugs can also be effective for treating or preventing some medical conditions associated with obesity. Food and Drug Administration recently approved Wegovy to reduce the risk of heart attacks, strokes and cardiovascular death in people who are overweight or obese, and Medicare drug plans can now cover Wegovy if it’s prescribed for that purpose.
Preventing serious medical conditions associated with obesity could theoretically also save employers money on health costs in the long term. But employers that cover GLP-1 drugs for weight loss generally do so as a special perk to attract top talent, not for the potential long-term savings - which they may never see, said Adam Okun, the employee benefits practice leader for the northeast region at Epic, a national insurance brokerage and consulting firm.
Covering these drugs can increase an employer’s overall health care costs by about 3%-5%, Okun said. He added that some companies seek to put up barriers to employees using the medications, such as imposing requirements that they also have to participate in lifestyle programs designed to encourage healthy habits and track their weight. Kalemkerian and other city employees on Zepbound who spoke with Gothamist said EmblemHealth began requiring them to participate in one such program, called WellSpark, earlier this year in order to renew their prescriptions. Some employers eventually decide to reverse course and stop coverage altogether once they see the price tag, Okun said.
Considerations for Semaglutide (Wegovy) Coverage
There must be documented evidence that the patient has previously attempted to lose weight through lifestyle modifications without adequate success. Continued use of Semaglutide must be part of a managed care plan that includes ongoing lifestyle modifications. If prior authorization requirements have not been met, EmblemHealth may refuse coverage for the medication. Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs.
Clinical trials demonstrate that Semaglutide (Wegovy) helps individuals lose a significant amount of weight. Wegovy is primarily for weight management in adults with obesity. Wegovy generally has higher dosing than Ozempic (up to 2.4mg vs. Though similar, they serve distinct medical purposes.
Alternatives and Additional Support
Compounded Medications
When patients stop taking GLP-1s, either because of a loss of insurance coverage or for other reasons, they often gain back the weight they lost and can experience other side effects such as depression, said Dr. Jennifer Ng, a primary care doctor at Mount Sinai. She added that she frequently talks to patients about the cost of these drugs, since insurance coverage varies widely. Some patients who can’t afford name-brand GLP-1s have opted for so-called "compounded” alternatives, which are typically cheaper.
Pharmacies and clinics are allowed to mix ingredients to make their own compounded version of an FDA-approved drug if the FDA declares that there’s a commercial shortage. That rule has been applied in recent years to popular GLP-1 weight-loss medications, although it’s unclear how long the approvals will last. Ng said she advises patients to avoid compounded drugs because of safety concerns. Compounded drugs are not individually reviewed and approved by the FDA, and the agency has cautioned that some patients have had bad reactions to compounded GLP-1s because of incorrect dosing. Some patients even had to be hospitalized.
Curex Services
Curex provides comprehensive care for those suffering from allergies, asthma and eczema. This includes customized sublingual immunotherapy, at-home concierge allergy testing, and symptom management. While it is difficult to estimate out-of-pocket costs prior to a claim being submitted, our team will work with you to make sure your treatment is as affordable as possible. The average patient responsibility is $200/year and depends on your plan (deductibles, coinsurance, telemedicine benefit). In addition, Curex accepts HSA and FSA.
Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.
Curex clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance. Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.
Curex providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster. Depending on your treatment goals, other medications such as metformin may also be considered. Curex recognizes the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Any prescriptions, including semaglutide, will be based on the expert assessment of the medical provider matched with you through our platform.
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