Finding time to maintain a healthy weight can feel nearly impossible due to work, errands, family responsibilities, stress, or limited access to nutritious food. Weight-loss drugs may seem appealing, but it's essential to understand their effectiveness, side effects, and insurance coverage. This article explores Kaiser Permanente's policies regarding weight loss medications, particularly focusing on Ozempic and related GLP-1 drugs, and offers guidance on navigating coverage complexities.
Understanding Weight Loss Medications
Weight-loss medicines may be an option for people who have obesity or who are overweight and have weight-related health problems, such as high blood pressure or diabetes. Several medications are approved by the Food and Drug Administration (FDA) to treat obesity or overweight, including:
- Semaglutide (Wegovy, Ozempic): May help you eat less.
- Liraglutide (Saxenda): This medicine may help you eat less.
- Tirzepatide (Zepbound): This medicine may help you eat less.
- Phentermine/topiramate (Qsymia): This medicine combines the drugs phentermine and topiramate.
- Bupropion/naltrexone (Contrave): This medicine may reduce your appetite.
- Orlistat (Xenical): Orlistat prevents some of the fat calories you eat from being absorbed in your intestines. It's also available without a prescription under the brand name Alli.
Different weight-loss medicines produce different results in each person. Weight-loss medicines are used long-term along with healthy eating and being more active. Many people regain some or most of the weight they lost if they stop taking the medicines. Weight loss medicines don't work for everyone.
The Role of GLP-1 Drugs
Lately, GLP-1 drugs are filling headlines for one reason: weight loss. But these drugs also have other, more harmful side effects. GLP-1s slow down your digestion and make you feel fuller longer, explains Dr. Ragasa. Some people who take them also have fewer cravings for processed foods. People usually stop taking GLP-1s for weight loss after 1 to 2 years, says Dr. Ragasa. “Without lifestyle changes, the weight loss people see while taking GLP-1s usually doesn’t last,” she explains. “Studies have shown that patients end up gaining about 60% to 70% of their weight again after coming off the medication.
While GLP-1s are popular right now and have helped many people lose weight, the side effects are still being studied. Keep in mind that no weight-loss drug is a substitute for a healthy lifestyle, and everyone’s needs are different.
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Kaiser Permanente's Coverage Policy
Kaiser Permanente’s coverage for weight loss drugs is primarily determined by specific medical necessity criteria. Insurance protection for slimming drugs varies significantly based on the specific plan and the medical necessity of the therapy. Most insurance providers, including Kaiser Permanente, generally cover treatments for obesity-related medical issues such as diabetes or hypertension when prescribed.
Starting January 1, 2025, Kaiser will implement an exclusion for certain weight loss medications unless they are prescribed for patients with a BMI over 40. Per California Title 28 Rule 1300.67.24(e)(3), GLP-1 drugs and other AOMs will still be covered under the base plan for patients with BMI equal to or greater than 40.
This change underscores the importance of understanding individual plan details and eligibility requirements. Kaiser Permanente will begin outreach to impacted members beginning November 21, 2024. This timing ensures that we’re accurately reaching out only to impacted members who are losing coverage in 2025. Clinicians are aware of the change in coverage and the optional weight loss drug rider for large commercial groups. Our core plans include comprehensive weight management, which may include medical weight management, tailored to each individual patient based upon their medical history and comorbidities.
To navigate these complexities, it is essential to familiarize yourself with the terms of your insurance policy, including any exclusions or requirements for prior authorization. Certain plans may require documentation of previous attempts to lose weight or evidence of obesity-related health concerns before approving support for GLP-1 therapy.
How to Determine Your Coverage
- Examine your Evidence of Coverage: This document outlines what is encompassed in your plan, including specific criteria for treatments related to reducing body mass, specifically addressing whether Kaiser covers weight loss drugs.
- Contact Customer Service: If you have any questions or need further clarification, reach out to Kaiser’s customer service. They can offer detailed information about your insurance and assist you with the required steps for obtaining prescriptions.
- Review the Formulary: The most effective way to check Ozempic coverage with a Kaiser plan is to review the formulary. This determines which drugs are covered, whether they have prior authorization or quantity limit requirements, and how much coverage the plan will issue.
Navigating Prior Authorization
Prior authorization is the process insurance companies use to confirm that a drug is truly medically necessary. For example, the Northwest Region cited above says they’ll cover Ozempic for weight management if the patient has a BMI of 30 kg/m2 or more-or if they have a BMI of 27 kg/m2 or more plus diagnosed hypertension, Type 2 diabetes, or hyperlipidemia.
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Let’s take the Kaiser Permanente Northwest Region as an example. For people with Type 2 diabetes, those plans will only cover Ozempic if the patient has already tried other drugs-like metformin and/or SGLT-2 inhibitors-plus has certain levels of raised A1c or contraindications to other viable drugs. That’s just one example, and it might vary significantly for other plans. Coverage not only varies by plan but can vary based on the reason for your Ozempic prescription. The medication is technically only FDA-approved to treat Type 2 diabetes, but it’s so effective at reducing body weight that healthcare providers often prescribe it off-label as a weight loss medication.
Recognizing shared obstacles to accessing obesity medications is essential for navigating the healthcare environment.
- BMI Requirements: Many insurance plans, including Kaiser Permanente, typically cover weight loss medications only for patients with a Body Mass Index (BMI) over 30 or those with obesity-related health conditions.
- Prior Authorization: Certain medications require prior authorization, meaning your healthcare provider must justify the prescription before approval is granted.
Reasons for Denial
Ozempic is requested for weight loss management in the absence of a diabetes diagnosis. When there is insufficient medical documentation supporting the necessity of starting or continuing Ozempic treatment. If Ozempic is prescribed outside FDA-approved indications without documentation of peer-reviewed evidence supporting its use for the specific condition or rationale provided. Recommending Ozempic for patients already achieving targeted glycemic control with their current medication regimen. Prescriptions that do not adhere to the pharmacy benefit plan or specific formulary restrictions imposed by Kaiser Permanente.
Appealing a Denial
If you encounter a denial, do not hesitate to appeal the decision and provide additional information as needed.
- Review the Denial Letter: Carefully examine the letter to understand the specific reasons for the denial.
- Contact Your Insurance Provider: Reach out to Kaiser’s customer service to discuss the denial.
- Submit Your Appeal: Send your appeal letter and all supporting documentation to the address specified in the denial letter.
- Follow Up: After submitting your appeal, follow up with your insurance provider to check on the status of your request.
In California, the average success rate for appeals regarding whether can vary, but many patients have successfully overturned denials by providing comprehensive documentation and demonstrating the clinical benefits of the medications.
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Remember, timely action is crucial; if your insurance is denied, addressing the issue promptly can help secure the necessary treatments for your health. Additionally, be informed that changes may arise regarding whether Kaiser Permanente covers weight loss drugs, as they will modify benefits for GLP-1 medications starting January 1, 2025, which may affect your appeal.
Costs and Savings
For many people, the big question is: What kind of dent will it put in my bank account? Without insurance, the average cost of Ozempic is around $1,351 for a single 2mg/3ml pen-usually a 30-day supply. Fortunately, insurance can significantly reduce those costs. How much, however, depends on how the plan’s formulary classifies Ozempic.
The approximate cost of Ozempic without insurance is between $800 and $900 for a month's supply.
If neither option is appealing, Kaiser beneficiaries can call the company’s support line to speak with a member services representative.
Ways to Reduce Costs
- Coupons: For example, coupons from SingleCare can knock off $500 or more. Signing up is free, and you just have to present your SingleCare card when you pick up your Ozempic from a partner pharmacy, then reap the discounts.
- Savings Card: Additionally, Noro Novdisk offers an Ozempic Savings Card for people who have partial coverage from private insurance. This card can save $100 for a one-month supply.
Lifestyle Changes and Alternatives
Getting fit is about more than just losing pounds. It’s about forming healthy, long-term habits. Eating healthy, being active, and managing stress are all part of improving your health and losing weight. When Dr. Ragasa prescribes weight-loss medication, she also recommends patients take up strength training and change their diet. “I tell my patients to choose high-quality proteins like beans and lentils. Any plant proteins naturally have vitamins, antioxidants, fiber, and all these nutrients that nourish the body,” she says. “When my patients stick to a more plant-based diet, they end up losing a significant amount of weight.
Being mindful about nutrition and exercise isn’t always easy. Creating a healthy lifestyle toolkit can help you when you aren’t sure what to eat or aren’t feeling motivated to exercise.
- Make a list of easy healthy recipes: Keep the list handy so you can reference it at the grocery store.
- Schedule a walk with a friend: Exercise doesn’t have to be a chore.
- Plan a healthy picnic: Getting outside for some fresh air and spending time with loved ones are both great for your health.
Additional Options
At Tyde Wellness, their program is designed for individuals seeking a personalized approach to weight loss and sustainable wellness. If you are overweight or obese (with a BMI of 25 or higher) or have one or more obesity-related conditions, you may be a suitable candidate for GLP-1 therapy.
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. Their service includes continuous support and regular follow-ups to ensure your treatment stays on track.