Obesity is a significant public health challenge in America, increasing the risk factors for serious health issues like heart disease, diabetes, and cancer. Effective weight management solutions are in high demand, with many adults interested in weight loss drugs. Highmark offers coverage for weight-loss drug prescriptions to treat obesity for Service Benefit Plan members who meet eligibility criteria and get prior approval. This article provides a detailed overview of Highmark's coverage policies, including specifics on medications like Semaglutide (Wegovy), requirements for prior authorization, and available weight management programs.
Highmark's Approach to Weight Management
Highmark views weight loss medications, including glucagon-like peptide-1 (GLP-1) receptor agonists, as part of a multi-faceted weight management program. A health plan member's chances of successfully managing weight are greatly improved when paired with lifestyle changes such as diet and exercise and side-effect management from a health care provider with expertise in managing patients with obesity. Highmark members have access to a variety of weight management and health improvement benefits, including nutrition counseling, fitness programs, and personalized health coaching.
Collaboration with Noom
In October 2025, Highmark announced a collaboration with preventive health leader Noom to support health plan members through a whole-person health approach to weight management. This partnership aims to provide a world-class customer experience by engaging members when, where, and how is best for them.
Eligible Highmark members, after enrolling and completing an onboarding assessment, will be matched to the right Noom journey based on acuity level. The journeys within Noom: Weight Management can be personalized for those at risk of developing diabetes as well as those living with type 2 diabetes. Noom offers several programs:
- Noom Weight: A digital program that helps members achieve and sustain a healthy weight through behavior change and lifestyle modification. It includes psychology-based lessons and AI-powered tools for smart food logging, body scan technology, and automated progress tracking.
- Noom Diabetes Prevention Program (DPP): Designed to help members lower their risk of developing type 2 diabetes. It uses a CDC-approved curriculum and has earned the CDC’s Full Plus Recognition.
- Noom Diabetes Lifestyle: A personalized lifestyle program that empowers members living with type 2 diabetes to take control of their health. It combines diabetes-specific education with practical tools like food logging and medication tracking.
- Noom’s GLP-1 Companion: Available to members across all journeys who self-report they are taking a GLP-1 medication.
Nearly 2 million Highmark members are eligible for Noom: Weight Management as part of their medical benefits with no additional, out-of-pocket cost.
Read also: Benefits of couples massage detailed
Coverage Details for Weight Loss Medications
Highmark covers weight-loss drug prescriptions to treat obesity for Service Benefit Plan members who meet eligibility criteria and get prior approval. Highmark's coverage policies are consistent with medical policy, state and federal mandates, and the evolving research on the effectiveness and safety of weight loss medications, including GLP-1s.
Prior Authorization Requirements
Prior authorization is typically required for weight loss medications. Initial authorization for Semaglutide is typically for a period of six months.
Specific Medications: Semaglutide (Wegovy)
Semaglutide, known as Wegovy, is primarily for weight management in adults with obesity. Clinical trials demonstrate that Semaglutide (Wegovy) helps individuals lose a significant amount of weight. Results vary, with some losing more and others less. Wegovy generally has higher dosing than Ozempic (up to 2.4mg vs. 2mg).
To confirm Wegovy's coverage tier, review Highmark’s prescription drug formulary.
Criteria for Coverage
Medicaid consumers in Pennsylvania prescribed medication for the treatment of obesity may be able to get these medications covered if they meet certain 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.
Read also: How digestive health affects weight loss
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).
Changes in BMI Threshold
Highmark has announced an increase in the BMI threshold from 27 or 30 to 40 for GLP-1 medications like Wegovy and Ozempic in Buffalo and Central New York. Patients currently using these drugs may need re-evaluation by their doctors to continue qualifying for coverage.
Financial Assistance
Patients are encouraged to seek patient assistance programs or discounts to help mitigate costs. Financial assistance provided by drug manufacturers may be available to help reduce out-of-pocket costs. You may have to re-enroll with a coupon card even if you used one last year.
Important Considerations
Discontinuation of Treatment
A significant portion of patients do not remain on weight loss medications long enough to realize the hoped-for health benefits. A May 2024 issue brief released by Blue Health Intelligence (BHI) found that about 60% of those taking GLP-1 medications for weight loss discontinued use before seeing a clinical benefit. There are serious issues with patients discontinuing treatment due to side effects like gastrointestinal problems.
Supply Shortages
There are also supply shortages of these medications, which has at times made them difficult to find for patients prescribed GLP-1s for diabetes.
Read also: Weight Loss Meds & BCBS
Alternative Medications and Compounding
Curex providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. They may prescribe treatments containing compounded semaglutide or tirzepatide. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.
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.
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. Curex also offers weight management programs tailored to individual needs. Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included.
Curex serves adults and children as young as 5 years old. Certain tests and treatments may be limited for younger kids.
Additional Highmark Benefits
Weight Management Program by Livongo®
Eligible members can get a digital scale and ongoing support to manage their weight and improve their health with the Weight Management Program by Livongo®. To participate, you must have a pediatric pharmacy or medical claim in the 85th percentile or higher within the last three years or an adult pharmacy or medical claim with a BMI of 25 or higher within the last three years.
Blue365®
With Blue365®, you can achieve your personal fitness goals on your budget.
Coverage for Morbid Obesity
FEP also covers procedures to treat morbid obesity, defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. Prior approval is required for surgery for morbid obesity.
Navigating Coverage and Costs
Reviewing Your Insurance Policy
Log into your Highmark member portal to review your current insurance policy details. Contact your member representative to ask about your ‘allergy, asthma, and telemedicine visit’ benefits.
Understanding Costs with Curex
While it is difficult to estimate out-of-pocket costs prior to a claim being submitted, the Curex 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.