This article provides a detailed overview of how to navigate Ozempic coverage for weight loss, specifically focusing on Geisinger Health Plan. It will cover eligibility, necessary steps, alternative options, and additional resources for those seeking coverage for this medication.
Understanding Ozempic and Its Use
Ozempic is a prescription medication primarily used to treat type 2 diabetes. However, it has also been shown to be effective for weight loss in some individuals. It belongs to a class of drugs called GLP-1 receptor agonists, which mimic the effects of a natural hormone in the body that helps regulate blood sugar levels and appetite.
Geisinger Health Plan Coverage for Ozempic
Geisinger Health Plan may cover Ozempic for eligible members as part of their prescription benefits. To qualify for coverage, individuals typically need a diagnosis of type 2 diabetes. It's important to note that prescription drug formularies, which detail covered medications, can change.
Eligibility and Requirements
- Diagnosis of Type 2 Diabetes: Typically, Geisinger Health Plan requires a diagnosis of type 2 diabetes to cover Ozempic.
- Prescription Drug Formularies: Keep in mind that the list of medications covered by Geisinger Health Plan (the formulary) can change, so it's essential to stay updated.
Steps to Obtain Ozempic Coverage with Geisinger
- Check Your Plan's Drug Formulary: This is a list of medications that your plan covers.
- Work with Your Healthcare Provider: Collaborate with your healthcare provider to submit any required paperwork to Geisinger Health Plan for prior authorization. Your health care professional is your prescribing physician, nurse practitioner, or physician assistant.
- Confirm Receipt of Prior Authorization: Contact Geisinger Health Plan to confirm receipt of the prior authorization request.
- Appeal if Denied: In case of denial, discuss with your healthcare provider about appealing the decision.
- Pick Up Prescription: Once approval is granted, go to your pharmacy to pick up the Ozempic prescription.
Prior Authorization: A Key Step
If your insurance doesn't provide coverage, or is unable to provide immediate coverage details, options that may help can be shared. If your insurance company might need to approve your prescription, don’t worry. This means that your health care professional will fill out a prior authorization form and submit it to the insurance company. The insurer will look at the prior authorization to determine whether they will cover the medicine under your insurance plan. It will communicate its decision and rationale to you and/or your health care professional. If your result is not covered, you may submit an appeal or request for coverage with the help of your health care professional.
Checking Cost and Coverage
Many people watch videos on their phones. To check your cost and coverage, you can head over to the main menu and click the "check your Cost and Coverage" button. It’s a platform from Novo Nordisk-maker of Wegovy, where you can check your insurance coverage for Wegovy and access a savings offer. Here, you’ll be asked some questions. To get started, you'll select if you're a patient or caregiver, and then move on to insurance details. After that, you’ll enter some key pieces of information including your name, date of birth, gender, and zip code. Once you've filled those out, go ahead and review them. If everything looks good, read the content and check the consent box at the bottom. Then, click the button underneath to continue. Here, you'll enter your health care professional's first and last name, city and state.
Read also: Benefits of couples massage detailed
What if Coverage is Undetermined?
Lastly, you could get a message saying that your coverage result is undetermined. This isn’t unusual, it just means that more information is needed.
Savings Options
If you have commercial insurance and are covered or covered with prior authorization, talk to your health care professional about whether Wegovy could be right for you. The Wegovy savings card can help lower those costs. It is important to note that government insured patients cannot use any copay cards offered by the manufacturer.
What if Ozempic is Not Covered?
If Geisinger Health Plan denies coverage for Ozempic, there are alternative options to consider:
- Appeal the Decision: Work with your healthcare provider to appeal the coverage denial.
- Explore Other Medications: Discuss alternative weight loss medications with your doctor.
- Patient Assistance Programs: Seek patient assistance programs or discounts to help mitigate costs.
- Curex: Get a personalized online consultation with a doctor at Curex.
- Bariatric Surgery: If you have patients who benefit from GLP-1s, but can't tolerate them for whatever reason, they may be great candidates to have bariatric surgery," said Geisinger CMO John Bulger. "There are a lot of patients that don't tolerate them and, in the end, whether people will continue to take them or not remains to be seen.
Understanding Semaglutide (Wegovy) Coverage with Geisinger Health Plan
Geisinger Health Plan does not cover Semaglutide (Wegovy) for weight management in patients that do not meet the specific Body Mass Index (BMI) criteria. Semaglutide (Wegovy) will not be covered if not prescribed specifically for chronic weight management. Coverage is denied if there is insufficient documentation of previous weight management attempts. Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs and regularly follow up with Geisinger Health Plan to monitor the status of your authorization request. If the authorization is denied, ask for clarification on the reasons and the appeal process.
Semaglutide (Wegovy) FAQ
- Efficacy: Clinical trials demonstrate that Semaglutide (Wegovy) helps individuals lose a significant amount of weight. Results vary, with some losing more and others less.
- Indication: Wegovy is primarily for weight management in adults with obesity.
- Dosage: While both are weekly injections, Wegovy generally has higher dosing than Ozempic (up to 2.4mg vs. Though similar, they serve distinct medical purposes.
Additional Options with Curex
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. The service includes continuous support and regular follow-ups to ensure your treatment stays on track.
Read also: How digestive health affects weight loss
Medications Prescribed by Curex Providers
Curex providers prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide. 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. If your care plan might include medication to ease symptoms like nausea, your well-being is always the top priority!
Compounded Medications
Compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person. Curex and its pharmacy partners do not have any association with Novo Nordisk.
Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list. These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.
Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list. Compounding pharmacies must have the proper licensed facilities and comply with state and federal regulations before dispensing these medications.
Insurance and Payment Options with Curex
Curex doesn’t require insurance. It offers clear and simple pricing, along with affordable medication options, making it easy and accessible to take care of your health and you can pay with your HSA or FSA card.
Read also: Weight Loss Meds & BCBS
Curex providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. They don’t prescribe Ozempic or Wegovy, but may prescribe treatments containing compounded semaglutide or tirzepatide. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.
Telehealth Options with Curex
Curex providers will review your information 100% online. Depending on where you live and the specifics of your medical history, providers may require you to have a video visit or asynchronous visit via text message. If prescribed, you’ll get unlimited online access to message your provider as needed for follow-ups, adjustments, and answers to your questions.
States Served by Curex
Currently, Curex does not serve Arkansas, Connecticut, and New Mexico.
Medicaid Coverage in Pennsylvania
Medicaid consumers in Pennsylvania prescribed medication for the treatment of obesity may be able to get these medications covered if they meet certain criteria. Medicaid coverage of these weight loss drugs is available to participants who meet the prior authorization criteria. Importantly, this includes people who have both Medicaid and Medicare, known as “dual eligibles”. Typically, Medicaid does not provide drug coverage for dual eligibles, who must get their medications covered through Medicare Part D (Medicare’s prescription drug benefit). However, Medicaid can cover certain medications excluded from the Medicare Part D benefit. Medicare Part D coverage rules specifically exclude coverage of prescription medications used solely for weight loss.
In order for Medicaid to cover these new weight loss drugs, a person’s doctor must submit a prior authorization request detailing that the patient meets the coverage criteria. Generally, to get these drugs covered, adults over age 18 must have a body mass index (BMI) of 30 or higher (or 27 or higher with certain additional requirements), and they must have at least one weight-related health condition. People who have diabetes or have used a diabetes drug in the previous 120 days have an additional requirement: they must try and fail treatment on one of the preferred diabetes treatment versions of the weight loss drugs, or another preferred diabetes drug in the same drug class (GLP-1 receptor agonists).
People have a right to appeal if Medicaid denies coverage for the new weight loss drugs after a doctor submits the prior authorization showing the patient meets the criteria.
Bariatric Surgery as an Alternative
Bariatric surgery refers to several different procedures, including gastric bypass or gastric sleeve, that reduce the size of a patient's stomach to change the way they eat. According to a 2019 study published in Surgery for Obesity and Related Diseases, an estimated 228,000 patients undergo bariatric surgery in the United States each year, or only 1% of the eligible population.
Some health plans are expanding coverage of bariatric surgery to cover more conditions. "If you have patients who benefit from GLP-1s, but can't tolerate them for whatever reason, they may be great candidates to have bariatric surgery," said Geisinger CMO John Bulger. "There are a lot of patients that don't tolerate them and, in the end, whether people will continue to take them or not remains to be seen. According to James Chambers, a professor at Tufts Medical Center, covering bariatric surgery for patients may be cheaper than covering weight-loss drugs for them, as the drugs can cost roughly $1,000 per month in perpetuity.
More primary care doctors are also working with surgeons to develop integrated treatment plans that combine surgery with weight-loss medication, said Kristal Hartman, board chair of the Obesity Action Coalition, a patient advocacy group that is supported by drugmakers, device companies, and providers.