The landscape of weight loss medications is evolving, with increased patient interest and a growing number of available treatments. However, understanding insurance coverage, particularly with Medical Mutual, can be complex. This article aims to provide clarity on Medical Mutual's weight loss medication coverage, explore available options, and offer guidance for navigating the process.
WeightWatchers Discounts for Medical Mutual Members
Medical Mutual offers discounted prices on WeightWatchers membership plans for its members covered under a health insurance plan. These plans start as low as $11.81 per month. Members can check their eligibility and join through the Medical Mutual website. Keep in mind that membership fees, co-pays, co-insurance, and deductibles may apply.
The Rise of Weight Loss Medications
Newer weight loss medications, especially GLP-1 receptor agonists, have garnered significant attention. Some of these medications, initially developed for diabetes treatment, have been rebranded and FDA-approved specifically for obesity. While older weight loss medications may have generic versions available, the newer drugs can be expensive. For example, a month's supply of Wegovy (semaglutide) was reported to cost around $1,300 in October 2022.
Insurance Coverage Landscape
Many insurers, including commercial insurers, Medicare, and Medicaid, often do not cover weight loss medications. Some insurers and employers view weight loss as a cosmetic need rather than a medical one. However, coverage can vary, with some plans covering certain weight loss medications with prior authorization, while others offer no coverage.
Medicare Coverage Restrictions
Medicare is generally barred from covering weight loss medications due to historical safety concerns. This restriction stems from the fallout of the fen-phen drug combination in the 1990s, which caused heart valve damage. While the Affordable Care Act expanded coverage for interventions like bariatric surgery, weight loss drugs remain largely excluded.
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When Coverage May Be Possible under Medicare Part D:
- If a medication has an FDA-approved indication beyond weight loss, Part D plans may cover it for that specific use.
- Coverage decisions are indication-specific; a drug may be covered for one use but not for weight loss.
- If prior authorization is needed, start with your doctor. Your plan reviews the request and sends a decision to you, your doctor, and your pharmacy.
- If step therapy applies, you may need to try a covered alternative first.
Important Considerations for Medicare Part D Coverage:
- Coverage and tiers vary by plan and state.
- Your costs depend on your specific plan, the pharmacy you use, and whether your medication is covered for your diagnosis.
- Plans can have a deductible (up to $590). You pay 100% for covered drugs until you meet it.
- After the deduction, you generally pay 25% coinsurance for covered drugs until you reach the annual $2,000 out-of-pocket maximum.
- High-cost medicines are often on a "specialty" tier. Plans can set specialty-tier coinsurance between 25% and 33% depending on the plans deductible.
- Adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) are $0, and covered insulin is capped at $35 for a one-month supply.
- The $2,000 cap and the above rules apply only to covered Part D drugs.
Medicare Coverage for Weight Management Services:
Even if a medicine isn’t covered for weight loss, Medicare still pays for several services that help manage weight and related conditions:
- Obesity Counseling Under Part B: Medicare covers intensive behavioral therapy when you have a Body Mass Index (BMI) of 30 or more and you receive counsel from a primary care practitioner in a primary care setting.
- Bariatric Surgery: Covered for certain conditions when medical criteria are met.
Medicare Advantage Plans
Wellcare Medicare Advantage plans may cover medications like Ozempic, Mounjaro, or Trulicity for Type 2 diabetes if the drug is on the plan’s Drug List and the patient meets the plan criteria. However, they are not covered for weight loss. Similarly, Wegovy may be covered only when prescribed to reduce cardiovascular risk in adults with established cardiovascular disease who are overweight or obese, and only if the plan lists it on the Drug List. Zepbound may be covered when prescribed to treat obstructive sleep apnea in adults with obesity, if the plan lists it and criteria are met.
The Treat and Reduce Obesity Act
Congress has been pushing for Medicare to cover weight loss medications, most recently with the Treat and Reduce Obesity Act of 2023 (H.R. 4818 and S. 2407). The Congressional Budget Office (CBO) is analyzing the potential for preventive medical care, including obesity treatment, to save money.
Arguments for Coverage
The American Medical Association and the Obesity Medicine Association consider obesity a disease and weight loss drugs a medical treatment. Furthermore, obesity is linked to cardiovascular and other related diseases. Data on Wegovy, for example, indicates cardiovascular benefits. Treating obesity can help prevent diabetes and heart disease, potentially saving payers money over time.
Eligibility for Weight Loss Medications
Eligibility for weight loss medications like Wegovy and Zepbound depends on factors such as BMI and the presence of comorbidities. Wegovy is approved for individuals with a BMI of 30 or greater, or a BMI of 27 or greater with comorbidities like high blood pressure, diabetes, or high cholesterol. Zepbound is approved for those with a BMI of 30 or greater and only for adults. Some GLP-1 agonists, as well as other medications like orlistat and Qsymia, are approved for ages 12 and older, while phentermine is approved for adolescents 16 and older.
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Trends in Weight Loss Medication Use
There has been a significant increase in interest and prescriptions for weight loss medications. Sales of semaglutide (including Ozempic and Wegovy) totaled $10.7 billion in 2021. From 2020 to 2022, prescriptions for these medications increased by 300%. Sales of anti-obesity medications stood at $1.1 billion for the second quarter of 2023, a 65 percent increase over the previous quarter.
Challenges and Considerations
Despite the increasing popularity of weight loss medications, many patients discontinue them within a year. Reasons for stopping include reaching a plateau in weight loss, inability to tolerate side effects, or medication shortages. Potential side effects of GLP-1 agonists include nausea, vomiting, diarrhea, dizziness, mild tachycardia, and headaches. There are also concerns about anesthesia complications and the risk of weight regain after stopping the medication.
Strategies for Patients
For patients whose insurance won't cover weight loss medications, comparison shopping and patient assistance programs can help. GoodRx allows patients to compare prices across pharmacies and look for coupons. Many drug makers offer patient assistance programs with discounted pricing.
Future of Medicare Coverage
The Centers for Medicare & Medicaid Services (CMS) is exploring a pilot program that could allow some Medicaid programs and Part D plans to cover GLP-1 drugs for “weight management,” with potential Medicare availability in 2027. However, details are not finalized and would go through public processes.
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