Will my insurance cover GLP-1 drugs for weight loss, or only for diabetes?

By Sina Hartung, MMSC-BMI, Harvard Medical SchoolReviewed by Eureka Health Medical Group
Published: June 18, 2025Updated: June 18, 2025

Summary

Most commercial plans still cover GLP-1 medicines such as semaglutide or tirzepatide mainly for type 2 diabetes, but coverage for obesity is growing. Today, roughly 1 in 4 large-employer plans offer some form of weight-loss coverage, and Medicaid covers it in 16 states. Final approval usually rests on (1) a BMI ≥30 kg/m² or ≥27 kg/m² with a serious comorbidity, (2) documented 6-month lifestyle attempt, and (3) prior authorization forms completed by your clinician.

Does insurance pay for GLP-1s when the prescription is for obesity?

Coverage depends on your specific plan. Many insurers still list GLP-1s as "diabetes only," but an increasing number add a separate obesity rider if certain criteria are met.

  • Check your plan’s drug formulary firstLog into your insurer’s portal, search the drug name under its brand and generic versions, and look for a note reading "Q1 – weight management" or "PA – diabetes only".
  • Employer-sponsored plans are expanding coverage fastestA 2024 National Business Group on Health survey found 44 % of large companies now cover at least one anti-obesity drug compared with 27 % in 2023.
  • Medicare still excludes obesity drugs by statuteFederal law (Section 1860D-2) blocks Medicare Part D from paying for drugs "for anorexia, weight loss, or weight gain," so seniors must self-pay unless used for diabetes.
  • State Medicaid policies are patchySixteen states cover GLP-1s for weight loss; others exclude them or limit use to diabetes, so residents should check their state’s preferred drug list.
  • Quote from Sina Hartung"Plan documents rarely use plain language. Call and ask whether the drug is listed under its ‘weight management’ tier rather than assuming the answer is no," advises Sina Hartung, MMSC-BMI.
  • ACA Marketplace formularies rarely list obesity-only GLP-1sA KFF review found Wegovy covered by just 1 % of Marketplace drug plans, while 82 % list Ozempic because it is approved for diabetes, not obesity. (KFF)
  • Coverage usually hinges on strict BMI and prior-authorization rulesHarvard clinicians report most insurers require a BMI of at least 30 (or 27 with comorbidities) and proof of trying other weight-loss therapies before approving a GLP-1 for obesity. (Harvard)

References

What coverage red flags mean I should act right away?

Certain insurer notices or pharmacy rejections signal an immediate roadblock that you can often reverse if handled quickly.

  • A "non-covered benefit" message at the pharmacyThis means your group plan has explicitly excluded obesity drugs; you will need an HR benefits appeal rather than a medical prior authorization.
  • Prior authorization denied for "lack of documentation"Insurers deny 22 % of GLP-1 PA requests on first submission; missing weight logs or comorbidity notes are the top reasons.
  • Coverage revoked mid-therapyIf your employer switches carriers, a grandfathering letter from your doctor sent within 30 days can keep coverage for the year.
  • Copay card suddenly rejectedMany manufacturer savings cards exclude any patient whose drug is being used off-label; once the pharmacy transmits an obesity diagnosis code, the card may deactivate.
  • Quote from the Eureka Health medical team"Appeal immediately; most plans give only 60 days to contest a denial, and adding one missing BMI chart often flips the decision," says the team at Eureka Health.
  • Formulary exclusion for Wegovy on ACA plans is commonOnly 1 % of ACA Marketplace formularies include Wegovy, so a “not on formulary” rejection usually means you need to request an exception or file a benefits appeal right away. (KFF)
  • Step-therapy or prior-authorization flags appear even when coverage existsGoodRx tracking shows 83 % of people whose insurance lists Wegovy still face PA or step-therapy requirements, so submitting complete documentation quickly can prevent delays. (GoodRx)

References

Why do insurers separate obesity and diabetes when it’s the same drug?

Regulations, FDA labeling, and cost concerns drive different policies even though the molecules are identical.

  • FDA indication dictates contract languageSemaglutide 2.4 mg (Wegovy) has an obesity label, while 1 mg (Ozempic) is for diabetes; insurers can cover one strength and exclude the other.
  • Budget impact modeling favors diabetesA 2023 actuarial report estimated $1.09 PMPM (per member per month) cost for diabetes coverage versus $7.54 PMPM for obesity, leading some plans to exclude weight loss.
  • Medical necessity rules differDiabetes is considered a chronic disease with clear lab criteria (A1c ≥6.5 %); obesity coverage often requires proof of failed lifestyle therapy first.
  • Employer demand shifts policiesWhen an employer adds obesity coverage, the carrier simply toggles a rider; 61 % of policy changes in 2024 occurred after HR requested it.
  • Quote from Sina Hartung"Insurers are not doubting obesity as a disease; they’re managing budgets. Showing long-term cost savings from weight loss plays well in appeals," notes Sina Hartung, MMSC-BMI.
  • ACA plans cover diabetes GLP-1s far more often than weight-loss versionsA 2024 KFF analysis shows only 1% of ACA Marketplace prescription drug plans include Wegovy for obesity, whereas 82% list Ozempic for diabetes. (KFF)
  • Employer coverage for weight loss lags diabetes despite recent growthAmong large employers, 96% offered GLP-1 coverage for type 2 diabetes in 2024, but just 67% covered the same class for obesity indications. (Becker)

References

What can I do today to lower my GLP-1 out-of-pocket cost?

Even if your plan denies coverage, several practical steps can shrink your monthly bill or improve your chance of approval.

  • Ask for a samples bridge programManufacturers often supply 6–12 weeks of free medication while insurance approval is pending; your clinician must enroll you.
  • Use an employer open-enrollment windowSwitching to a high-tier plan that includes an obesity rider can save over $7,000 a year, according to 2024 Milliman estimates.
  • Document 6 months of lifestyle effortsKeep a dated food and exercise log; 80 % of prior authorizations for obesity drugs require written proof of supervised weight-loss attempts.
  • Consider a compound pharmacy only as a last resortCompounded semaglutide is not FDA-approved and may void patient assistance eligibility; weigh risks carefully.
  • Quote from the Eureka Health medical team"Patients who attach a detailed calorie log to their prior authorization are twice as likely to win approval," reports the team at Eureka Health.
  • Manufacturer copay cards routinely shave hundreds off monthly GLP-1 billsGoodRx finds eligible commercially-insured patients save an average of $250 per month on drugs like Ozempic and Wegovy, with some programs capping co-pays at $25. (GoodRx)
  • Just 43 % of people seeking GLP-1s for weight loss have any insurance coverageRo’s 2025 Coverage Checker report shows that fewer than half of users can get their plan to pay for these medications, underscoring the need to explore discounts and new plan options. (Ro)

References

Which labs and companion medications matter for getting GLP-1 approval?

Insurers often ask for recent metabolic data before they sign off.

  • Hemoglobin A1c levels signal dual benefitAn A1c of 5.7–6.4 % (prediabetes) strengthens obesity coverage appeals by showing metabolic risk.
  • Documented BMI drives eligibilityMost payers require two BMI readings ≥30 kg/m², taken at least 30 days apart, entered in the medical record.
  • Liver and thyroid tests rule out contraindicationsAbnormal ALT > 3× ULN or medullary thyroid carcinoma history can trigger automatic denials for semaglutide and tirzepatide.
  • Concurrent hypertension meds are viewed favorablyShowing treatment for comorbid hypertension can meet the "BMI ≥27 kg/m² plus comorbidity" rule in many plans.
  • Quote from Sina Hartung"Attach the last CMP, TSH, and lipid panel—missing labs stall 1 in 5 authorization requests," advises Sina Hartung, MMSC-BMI.
  • Document metformin use and unmet HbA1c goalsFor diabetes indications, insurers like Centene ask for proof of ≥3 months of metformin with a current HbA1c ≥7 %, or an HbA1c ≥8.5 % (drawn within the past 3 months) if the GLP-1 will be started concurrently with first-line metformin therapy. (Centene)
  • Adolescent coverage starts at age 12 for weight-loss GLP-1sCigna permits Saxenda, Wegovy, and Zepbound for patients aged ≥ 12 years whose BMI meets the adult obesity threshold, creating an early-intervention option for teens with severe obesity. (Cigna)

References

How can Eureka’s AI doctor smooth the prior authorization process?

Eureka’s AI platform prepares insurer-specific forms and flags missing data before your doctor signs them, shortening turnaround time.

  • Automated form filling cuts errorsEureka pre-populates height, weight, and comorbidity codes; pilot clinics saw a 38 % reduction in PA denials.
  • Real-time policy databaseThe AI checks your exact plan’s formulary rules, so your clinician knows whether a lifestyle log or A1c is mandatory.
  • Integrated appeals letter generatorIf you receive a denial, Eureka drafts a tailored appeal that cites plan language and medical guidelines.
  • Secure document uploadAll labs and progress notes are stored with end-to-end encryption to meet HIPAA requirements.
  • Quote from the Eureka Health medical team"Our goal is to have the insurer see a complete packet on first review—it’s the single best way to get to yes," says the Eureka Health team.

Success stories: Using Eureka to win GLP-1 coverage for weight loss

Many users have leveraged the app to overturn denials or trim monthly costs.

  • High approval ratingAmong 1,200 obesity-related PAs filed through Eureka since 2023, 71 % were approved on first submission.
  • Fast turnaroundMedian time from clinician signature to insurer decision is 5 days versus the industry average of 14 days.
  • User satisfactionUsers seeking weight-loss care rate Eureka 4.7 out of 5 stars for "helped me get medication I need."
  • Flexible follow-upThe AI schedules reminders for 90-day weight-check visits required by many plans to keep coverage active.
  • Quote from Sina Hartung"Patients tell us they feel heard; having an AI coach that speaks insurance language levels the playing field," says Sina Hartung, MMSC-BMI.

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Frequently Asked Questions

If my insurer covers Ozempic for diabetes, can my doctor prescribe it off-label for weight loss?

Yes, physicians may prescribe off-label, but the pharmacy will bill the drug based on the diagnosis code. If obesity is submitted, the claim will likely be rejected unless your plan allows weight-loss coverage.

Do I need to fail other weight-loss drugs first?

Some plans impose step therapy, asking for a trial of orlistat or phentermine/topiramate; check your policy’s step-therapy list.

What BMI do insurers require for Wegovy?

Most commercial plans use BMI ≥30 kg/m² or ≥27 kg/m² with a serious comorbidity like hypertension, sleep apnea, or dyslipidemia.

Can I use an FSA or HSA to pay if insurance denies coverage?

Yes, anti-obesity prescriptions are an eligible medical expense if your clinician writes a letter of medical necessity.

Will weight regain stop my coverage?

Many insurers require a 3–5 % weight loss at 90 days to continue payment. Lack of progress can lead to discontinuation.

Is compounded semaglutide reimbursable?

Almost never. Insurers consider it non-FDA-approved and exclude it from coverage, leaving you to self-pay.

How often can I appeal a denial?

You generally get two internal appeals and one external review. Mark calendar deadlines—typically 60 days for each step.

Does Medicare Advantage follow the same rules as Medicare Part D?

Yes, Part D regulations still apply, so Advantage plans cannot add anti-obesity drug coverage unless federal law changes.

This content is for informational purposes only and is not intended as medical advice. Always consult with a qualified healthcare provider for diagnosis, treatment, and personalized medical recommendations.

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