The landscape of weight loss medication coverage is constantly evolving, particularly concerning GLP-1 drugs like Ozempic and Wegovy. This article delves into the intricacies of IEHP (Inland Empire Health Plan) Ozempic coverage for weight loss, examining current policies, potential future changes, cost-saving strategies, and alternative treatment options.
Understanding GLP-1 Medications and Their Uses
GLP-1 (glucagon-like peptide-1) drugs have been used as a treatment for type 2 diabetes for over a decade, but newer forms of these drugs have gained widespread attention for their effectiveness as a treatment for obesity. Many GLP-1 medications, such as Ozempic, are intended to treat Type 2 diabetes, but in recent years, millions of Americans have turned to them for weight loss management.
Ozempic and Wegovy both contain semaglutide, a glucagon-like peptide-1 (GLP-1) receptor agonist, but their doses are different. Ozempic is used to control blood sugar in type 2 diabetes and help protect the kidneys, while Wegovy is prescribed for long-term weight management and certain forms of liver disease. These medicines are given as once-weekly subcutaneous injections (by a needle under the skin) in your stomach (abdomen), thigh, or upper arm area.
Current IEHP and Medicaid Coverage Policies
Most GLP-1 agonists, including Ozempic, are usually covered by state Medicaid programs for the treatment of type 2 diabetes. Prescription coverage for Medicaid plans is often determined by individual states. Many states may not cover weight-loss drugs for Medicaid recipients, or may have special requirements before coverage begins.
IEHP, as an HMO-based regional plan, typically follows FDA guidelines and may not require additional criteria to be met for medication coverage for its approved uses. They also don’t require prior authorization. However, it's crucial to verify benefits with IEHP directly, as coverage can vary by provider and policy.
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Potential Expansion of Coverage: Medicare and Medicaid
Medicare and Medicaid could expand coverage of GLP-1 drugs, such as Ozempic and Wegovy, and pay for patients’ use of the weight loss drugs, according to a new report. State Medicaid programs and Medicare Part D plans could soon voluntarily choose to cover these drugs for “weight management,” The Washington Post reports, citing internal documents from the Centers for Medicare and Medicaid. The proposed plan, which has not been finalized, would start in April 2026 for Medicaid and in January 2027 for Medicare.
Covering the drugs for weight loss would cost Medicare an estimated $35 billion from 2026 to 2034, the Post reports. However, Medicare is negotiating lower prices for Ozempic and Wegovy in 2027. Currently, the popular drugs can cost upwards of $1,200. These negotiations could save consumers money. Some experts have argued that Medicare prices can serve as a benchmark for private insurance companies and lead to savings, according to the health non-profit Kaiser Family Foundation. More insurers could also be pressured to provide coverage for these medications for weight loss if states opt into the proposed program.
This proposal comes after the Trump administration said in April that Medicaid and Medicare would not cover GLP-1 drugs for weight loss, the Post reports. This ended a previous plan under Joe Biden’s administration to cover the drugs. Members of the Trump administration may also be divided on the issue. Centers for Medicare and Medicaid Administration Mehmet Oz has previously called the drugs a “big help,” while Health and Human Services Secretary Robert F. Kennedy Jr. has raised concerns about the cost of the drugs, the Post reports.
Factors Influencing Coverage Decisions
States are likely considering various cost containment strategies for these drugs and may even be re-evaluating their broader approach to obesity treatment, including the use of obesity medications along with other treatments such as nutritional counseling or behavioral therapy.
When asked about the key factors contributing to their obesity medication coverage decision, almost two-thirds of responding states mentioned cost, though states are also weighing a number of other factors including the need for legislative action, adherence concerns, clinical criteria development, and potential side effects. Conversely, 4 in 10 states noted that positive health outcomes and longer-term savings on chronic diseases associated with obesity were key factors in their decision to cover or consider covering in the future along with increasing enrollee access and health equity, recommendations from providers, and ability to negotiate supplemental rebate agreements.
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The Role of Prior Authorization
If your doctor prefers that you receive Ozempic, they may need to complete a Prior Authorization form to be reviewed and approved by your insurance company. This form will help explain the medical reason why you need Ozempic over other options. This can help increase the chances that your insurance will cover some of the costs for the medicine.
PPO insurances require Prior Authorization. Additionally, they often will not pay for the medication unless a patient meets a higher need for the medication. These criteria often include documentation of participation in lifestyle intervention consisting of a reduced calorie diet, increased physical activity and behavioral modifications for 6 months within the last year. Some PPO insurances may not consider covering this medication at all unless your BMI is above 40.
If your insurance doesn't provide coverage, or is unable to provide immediate coverage details, we can share options that may help. It means that your health insurance company might need to approve your prescription. 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.The Prior Authorization process can take up to 2 weeks to complete. Our insurance specialists will gather your medical history to support medical necessity and will send a formal request for coverage to your insurance company.
Navigating Cost and Savings Options
The cost for Ozempic typically runs between $0 and $1029 per month. Because these drugs are typically used long-term for weight loss, costs can add up if you must pay a significant amount each month.
Novo Nordisk, the manufacturer of Ozempic, may be able to offer you copay assistance if you have commercial insurance. You could pay as little as $25 for up to a 3-month supply of Ozempic. For eligible people with commercial (private) insurance that covers Ozempic, the Novo Nordisk Savings card can offer a maximum savings of $150 for a 1-month prescription, $300 for a 2-month prescription, and $450 for a 3-month prescription. Copay assistance is not valid for people using government-assisted programs, such as Medicare, Medicaid, VA, Tricare or any similar federal or state health care program.
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If you do not have insurance, Novo Nordisk may be able to offer patient financial assistance for Ozempic based on your income eligibility.
Alternative Medications and Treatment Approaches
Ozempic use for weight loss is considered “off-label” and is not approved by the FDA. Wegovy is a weekly GLP-1 agonist injectable medicine approved for weight loss that contains the same active ingredient as Ozempic, called semaglutide, but in a higher dose.
Mounjaro (tirzepatide) is an injection used weekly to lower blood sugar in type 2 diabetes and has also been shown in studies to be useful for weight loss, but it is not approved for this use. If you prefer an oral GLP-1 treatment, Rybelsus is a once-a-day tablet formulation of semaglutide, first approved in Sept.
Weight loss drugs that suppress the appetite are known as anorexiants and contain a stimulant medication similar to amphetamine. Stimulants are classified as controlled substances by the Drug Enforcement Agency (DEA) because they have a risk for abuse and addiction.
Lifestyle Modifications and Comprehensive Weight Management
Gradual weight loss is the most effective and safest way to lose weight. You can expect to start losing weight within a few months, especially if you implement a reduced calorie diet and a bit of exercise to your daily routine. In a clinical trial published in the New England Journal of Medicine, people who combined Wegovy (semaglutide) with a healthy diet and exercise lost an average of 4% of their body weight after just eight weeks. In the first 20 weeks of treatment, participants had lost an average of 10% of their body weight, and 15% of their body weight in just over a year of treatment (68 weeks).
The Increasing Utilization and Spending on GLP-1s
The number of Medicaid prescriptions and gross spending on GLP-1s have increased rapidly in recent years, with both nearly doubling from 2022 to 2023. Overall, from 2019 to 2023, the number of GLP-1 prescriptions increased by more than 400%, while gross spending increased by over 500%. Spending per prescription before rebates reached more than $900 per prescription in 2023.
Potential Side Effects and Management
Your provider may have sent medication for you already that is meant to avoid common side effects. These medications may include Zofran (ondansetron) for nausea, Mira-Lax (polyethyline glycol) for constipation, Pepcid (famotidine) for heartburn, and vitamins for use. If not, please reach out to us and we can send a prescription to help with common side effects. Rarely, more severe side effects can occur with any of the GLP-1 medications.
The Future of GLP-1 Coverage
Many state Medicaid programs are considering covering obesity drugs in the future but are concerned about the cost implications. KFF’s annual budget survey found that, among those states that do not currently cover obesity drugs, half reported they were considering adding coverage, with a few states reporting plans to add or expand coverage in FY 2025 or later.