Weight loss medications can be a valuable tool in managing chronic weight issues when combined with a healthy diet and regular exercise. These drugs typically work by curbing appetite and reducing daily caloric intake, leading to significant health improvements such as lower risks of diabetes, hypertension, and heart problems, along with increased energy. This article delves into how Oscar Health insurance covers weight loss medications, eligibility criteria, and alternative options like Curex.
Weight Loss Medications: A Comprehensive Approach
A comprehensive strategy for weight loss usually involves a combination of dietary adjustments, physical activity, and, in some cases, medication. Drug therapy is often considered for individuals classified as obese or those with co-existing health conditions. Weight loss medications come in different forms, including oral tablets like Contrave and Qsymia, and injectable solutions like Saxenda and Wegovy.
It's important to note that coverage for prescription drugs intended for obesity treatment, weight reduction, or dietary control can vary significantly based on the specific benefit policy of the member. To understand the specifics of your coverage, it's essential to refer to your benefit plan document, which outlines the terms and conditions. The guidelines discussed here apply only to members whose plans include prescription drug coverage for weight loss or dietary control.
Key Definitions
- Body Mass Index (BMI): A calculation using an individual's weight and height to categorize them as underweight, normal weight, overweight, or obese.
- Caloric Intake: The daily amount of energy, measured in calories, that a person consumes through food and beverages.
- Compendia: Authoritative summaries of drug information and medical evidence used to support decisions about appropriate drug and medical procedure use. Examples include the American Hospital Formulary Service Drug Information and the United States Pharmacopeia-National Formulary (USP-NF).
Medical Necessity Criteria for Initial Authorization
Oscar Health considers weight loss agents medically necessary when specific criteria are met:
Age Appropriateness: The prescribed medication must be appropriate for the member's age, in accordance with FDA approval or evidence-based guidelines.
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Documentation of BMI:
- For adults: A BMI of 30 kg/m² or greater, or a BMI of 27 kg/m² or greater with at least one weight-related comorbidity such as cardiovascular disease, dyslipidemia, hypertension, obstructive sleep apnea, or type 2 diabetes mellitus.
- For pediatrics: Usage aligned with the specific medication's FDA approval or evidence-based guidelines, based on BMI percentile standardized for age and sex.
Baseline Body Weight: Documentation of the member’s body weight before starting treatment.
Participation in a Weight Management Program: Evidence of at least 6 months of participation in a comprehensive weight management program before starting drug therapy, with documented body weight before and after the program.
Adjunct Therapy: The medication must be used alongside a reduced-calorie diet and increased physical activity.
No Combination with Other Weight Loss Products: The medication should not be used in combination with other weight loss products, including prescription drugs, over-the-counter medications, or herbal preparations, unless specifically recommended in the drug's official prescribing information.
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Approved Medications and Durations
If the above criteria are satisfied, Oscar Health may approve the following weight loss medications for the specified durations:
- For 12 weeks: Adipex-P (phentermine), Alli (orlistat), Bontril PDM® (phendimetrazine), Bontril Slow Release (phendimetrazine), Contrave (naltrexone HCI/bupropion HCl), Didrex (benzphetamine), Lomaira (phentermine HCL), Qsymia (phentermine/topiramate), Regimex (benzphetamine), Suprenza (phentermine), Tenuate (diethylpropion), and Xenical (orlistat).
- For 16 weeks: Saxenda (liraglutide) and Wegovy (semaglutide).
- For 6 months: Zepbound (tirzepatide).
Medical Necessity Criteria for Reauthorization
For continued coverage, specific medications like Alli, Contrave, Qsymia, Saxenda, Wegovy, Xenical, or Zepbound require reauthorization every six months. The member must provide recent chart documentation (within one month) showing:
Continued Lifestyle Modifications: Ongoing adherence to a reduced-calorie diet, physical activity, and behavioral therapy.
Clinically Meaningful Weight Loss:
- For adults: A weight loss of at least 5% of baseline body weight.
- For pediatrics: A reduction of at least 5% of baseline BMI.
It is important to note that Adipex-P, Bontril PDM ®, Bontril Slow Release, Didrex, Lomaira, Regimex, Suprenza, and Tenuate are not eligible for reauthorization.
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Experimental or Investigational Treatments
Oscar Health considers weight loss medications for any other indication not medically necessary, deeming them experimental, investigational, or unproven. The use of Adipex-P, Bontril PDM, Bontril Slow Release, Didrex, Lomaira, Regimex, Suprenza, and Tenuate for long-term weight management is also considered not medically necessary.
Navigating Coverage for Specific Medications: Semaglutide (Wegovy) and Phentermine
Semaglutide (Wegovy)
To navigate coverage for Semaglutide (Wegovy) with Oscar Health:
- Review Your Policy: Check your specific Oscar Health insurance policy for details on medication coverage.
- Consult Your Doctor: Discuss your need for Wegovy with your doctor to confirm it’s the appropriate medication for your condition.
- Prior Authorization: Work with your physician to submit a prior authorization request to Oscar Health.
- Check Authorization Status: Contact Oscar Health customer service to confirm the status of your prior authorization request.
- Pharmacy Verification: Once approved, verify which pharmacies are in-network with Oscar Health to fill your prescription.
- Appeals: If your request is denied, file an appeal.
- Stay Updated: Keep up-to-date with any policy changes by Oscar Health that could affect your coverage of Semaglutide (Wegovy).
Phentermine (Adipex-P, Lomaira)
For Phentermine coverage:
- Age and Diagnosis: Ensure the patient is 16 years or older and has a diagnosis of obesity, defined by a BMI of 30 kg/m² or greater.
- Price Variation: Be aware that the price of Phentermine can vary based on the pharmacy location and dosage strength. Lomaira, a lower-dosage version of Phentermine, might have different pricing.
- Retail Prices: Note that the listed costs are retail prices, and cheaper generic options may be available.
Alternative Options: Curex
If navigating insurance coverage proves challenging, consider alternative options like Curex. Curex offers comprehensive care for allergies, asthma, and eczema, including customized sublingual immunotherapy, at-home allergy testing, and symptom management.
Benefits of Curex
- Accessibility: Curex offers convenient and affordable allergy and asthma care for everyone.
- Comprehensive Care: Services include customized sublingual immunotherapy, at-home concierge allergy testing, and symptom management.
- Financial Options: Curex accepts HSA and FSA cards.
- Personalized Treatment: Treatment plans are customized based on medical profile, test results, and lifestyle needs.
- Medication Options: If medication is prescribed, options may include GLP-1 treatments such as compounded semaglutide, along with other medications like metformin or supplements such as vitamin B12.
Important Considerations for Curex
- Insurance Billing: While Curex bills insurance for each quarterly visit, payment is not guaranteed and depends on your health insurance company.
- Out-of-Pocket Costs: The average patient responsibility is $200/year, depending on your plan's deductibles, coinsurance, and telemedicine benefits.
- Compounded Medications: Note that compounded medications are tailored to individual needs but are not FDA-approved for safety or effectiveness.
Additional Resources and Considerations
- Meto: Meto accepts most Oscar Health plans for metabolic health and longevity care services, including consultations, lab testing, and prescription support.
- Oscar Health Policy Changes: Stay informed about any policy changes that could affect your coverage of weight loss medications.
- Patient Assistance Programs: Explore patient assistance programs or discounts to help mitigate costs.