In recent years, weight loss medications have become increasingly popular as more individuals look for medical intervention to manage their body weight, especially when weight gain is associated with chronic conditions such as diabetes, thyroid issues, mental health and hormonal imbalances. However, the journey to access weight loss medications can be challenging due to the intricacies of insurance coverage. Many insurance companies only cover specific medications, including those for weight loss, when prescribed for certain conditions.
1. What are Weight Loss Medications?
Weight loss medications, also known as weight loss drugs or anti-obesity medications, are prescription medications that can be prescribed to help individuals who are struggling to lose weight through diet and exercise alone. These medications are generally recommended for individuals with a body mass index (BMI) of 30 or higher, or for those with a BMI of 27 or higher who also suffer from weight-related health conditions like high blood pressure or type 2 diabetes.
There are several approved prescription weight loss drugs currently available on the market, including:
- Semaglutide (Ozempic, Wegovy, or Rybelsus): These medications belong to a group of medications called glucagon-like peptide-1 (GLP-1) receptor agonists. These medications help your body produce more insulin and control blood sugar levels by mimicking naturally occurring hormones released after meals, making you feel fuller.
- Tirzepatide (Mounjaro): Targets two key digestive hormones: GLP-1, which lowers blood sugar levels after meals and helps curb appetite, and GIP, which encourages your body to release insulin more controlled.
- Liraglutide (Saxenda): Saxenda belongs to the glucagon-like peptide-1 (GLP-1) receptor agonists group that cleverly mimics a natural hormone in your body that boosts insulin levels and suppresses appetite. It slows digestion, extending the feeling of fullness, which is beneficial for managing blood sugar and weight control.
You do not need insurance coverage to be prescribed these medications. However, given that these medications can be $200-$500 per month in Canada, patients may insurance coverage to afford them.
2. Insurance Coverage for Weight Loss Medications
Despite the increasing awareness of the benefits of weight loss medications, many individuals find that their insurance policies do not automatically cover these treatments. Insurance companies are often reluctant to provide coverage for weight loss drugs, even though obesity and related conditions can lead to serious health problems, including high blood pressure, heart disease, and diabetes.
The first step in navigating insurance for weight loss medications is to understand your specific policy. Contact your insurance provider to ask about their coverage for weight loss drugs, what criteria you need to meet, and whether any specific steps, like obtaining special authorization, are required.
3. What is Special Authorization?
Special authorization is a process used by many insurance companies to approve coverage for medications that are not typically included in their standard drug plans. For weight loss medications, this often means proving that the drug is medically necessary for managing your health conditions.
The process generally involves your healthcare provider submitting a request to the insurance company on your behalf. This request will include detailed information about your medical history, including your body weight, BMI, and any conditions you suffer from, such as high blood pressure, diabetes, or heart disease. The goal is to demonstrate that weight loss medication is essential for improving your health and that other methods of weight loss, such as diet and exercise alone, have not been sufficient.
4. Frequently Asked Questions on Special Authority
What is the process of special authority or prior authorization coverage for weight loss medications in Canada?
Special Authorization and Prior Authorization are terms used interchangeably to describe the pre-approval process for specific prescription medications. This process helps determine whether certain weight loss prescription medications will be reimbursed under the benefits plans. Most prescription medications that require special authorization are considered high-cost drugs, such as Ozempic or Wegovy.
How do I know if my weight loss medication requires special authorization?
This depends on the insurance provider. If you have health benefits through your employer, the first step is to search for the medication name on your health benefits provider portal or mobile app.
How long does it take to get the prior authorization approved?
Most insurance companies are currently backlogged, which means your prior authorization could take up to 4-8 weeks for approval. Some insurers may even include the wait time of a high volume of requests such as prescription weight loss medications.
A typical process to getting your weight loss medications covered could look like the following:
1. Complete the prior authorization form. (DooU team needs to collect all the relevant information about the user's medical and drug history, which takes 3-5 business days)
2. DooU's practitioner will review the details and may reach out to the patient for more information. (2-3 business days)
3. Once the patient sends the form to their insurance company, they will review the patient's medication and disease history and might reach out to the primary physician to get more details. (3-4 weeks)
4. The insurance company will send an email or letter to the patient for approval or denial (3-4 weeks)
Based on our experience, unfortunately, 98% of the users who do not have chronic conditions like diabetes or high blood pressure do not qualify for weight loss treatment with Ozempic and Mounjaro.
What medications are more likely to be approved for special authorization?
Health Canada regulations will approve some medications for weight loss, that are primarily used for managing type 2 diabetes. As per Health Canada regulations, Ozempic and Mounjaro are approved for diabetes, and Wegovy and Zepbound (not yet approved in Canada) are approved for weight loss.
5. Is My Medication Covered for Weight Loss Under Health Canada?
Is Ozempic covered for weight loss under my health benefits plan?
No. The majority of insurers in Canada do not cover Ozempic for weight loss. Per Health Canada guidelines, Ozempic is a diabetic medication and is only covered if other diabetic therapies are ineffective; each insurer has its criteria for Ozempic coverage. For example, Canada Life asks the following questions for the Ozempic special authorization:
1. The doctor must provide the medical rationale for prescribing this drug instead of an alternate drug in the same therapeutic class.
2. Does the user have an HbA1c level of 7% or more?
3. Does the user have inadequate glycemic control despite diet and exercise?
4. Has the user had an inadequate response to the maximum tolerated metformin dose?
5. Attach a drug and treatment history chart (which is only available at your family doctor)
We recommend you check with the benefit provider or HR or Benefits manager for more details.
Is Wegovy covered for weight loss under my health benefits plan?
Per Health Canada regulations, Wegovy is approved under the weight loss category and might be covered under your benefits. We recommend you check with the benefit provider or your employer for more details.
Is Mounjaro covered for weight loss under my health benefits plan?
No. Per Health Canada regulations, Mounjaro is approved for diabetes, and you might need to fill out the prior authorization form for coverage. We recommend you check with the benefit provider or your employer for more details.
Is Contrave covered for weight loss under my health benefits plan?
Per Health Canada regulations, Contrave is approved for weight loss, and you might need to fill out the prior authorization form for coverage. We recommend you check with the benefit provider or your employer for more details.
Is Rybelsus covered for weight loss under my health benefits plan?
No. Per Health Canada regulations, Rybelsus is approved for diabetes, and you might need to fill out the prior authorization form for coverage. We recommend you check with the benefit provider or your employer for more details.
6. Why Insurance Companies Deny Coverage for Prescription Weight Loss Drugs
Many insurance companies are reluctant to cover weight loss medications because they classify them as "lifestyle" or "cosmetic" treatments rather than necessary medical interventions. This is despite the fact that excess body weight is a major risk factor for numerous health conditions, including high blood pressure, heart disease, and certain types of cancer.
Some of the common reasons why insurance companies deny coverage include:
- Perceived lack of medical necessity: If your insurance provider doesn’t believe that weight loss medication is essential for managing your health, they may deny the request.
- Failure to meet BMI or other criteria: Insurance companies often have strict criteria for covering weight loss medications. For example, you may need to have a BMI over a certain threshold or be diagnosed with a weight-related health condition like high blood pressure.
- Incomplete or insufficient documentation: If the special authorization request lacks sufficient medical documentation or details, it may be rejected.
Conclusion
Navigating the insurance process for weight loss medications can be daunting, but with persistence, thorough documentation, and the support of your healthcare provider, it’s possible to secure the coverage you need. Understanding the role of special authorization and working closely with your insurance company are essential steps in ensuring access to weight loss drugs that can help you achieve your health goals and manage conditions like high blood pressure more effectively.
By taking a proactive approach and staying informed, you can increase your chances of obtaining insurance coverage for the weight loss medications that can help you lead a healthier, more fulfilling life.
