Learn how major insurance providers determine coverage for innovative weight loss medications like tirzepatide and semaglutide.
In 2022, the FDA approved two new promising medications for chronic weight management: tirzepatide and semaglutide.
But those needing help paying for these expensive novel drugs quickly asked: will insurance cover them?
Unfortunately coverage varies greatly between plans. This article breaks down how major providers like UnitedHealthcare, Cigna and Blue Cross Blue Shield analyze tier placement, prior authorization criteria, and other factors guiding approval odds for drugs like tirzepatide vs semaglutide cost!
How Tirzepatide & Semaglutide Aid Weight Loss?
Tirzepatide and semaglutide exemplify an emerging drug class called GLP-1 receptor agonists.
As injectable prescription medications, they stimulate GLP-1 receptors to influence blood sugar control and appetite signals.
The end result for most is 5-15% body weight reduction meeting or exceeding results from older medications like phentermine or orlistat.
| Medication | Brand Name | Average Weight Loss | Frequency |
| Tirzepatide | Mounjaro | Up to 22% of body weight | Weekly injection |
| Semaglutide | Wegovy, Ozempic | Up to 15% of body weight | Weekly injection |
With superiority to older anti-obesity medications, it’s no wonder new GLP-1 drugs provoke immense excitement yet simultaneously restrictions from insurers concerning premium costs.
Next we’ll break down the step-by-step process of gaining pharmaceutical coverage.
Navigating the Insurance Coverage Maze
Gaining access to the astronomical price tags of novel specialty drugs through insurance is no cakewalk.
But by understanding the tier system, appeal channels and prior authorization processes governing approval, your odds improve tremendously.
Let’s walk through step-by-step what transpires after your provider submits a coverage request to your insurance company.
Step 1: Tier Placement Evaluation
The first factor determining coverage is which drug tier your insurance provider places tirzepatide/semaglutide into, as this sets parameters around copays and other rules. Typical tiers include:
Tier 1 – Lowest copay for generics and select brand names
Tier 2 – Moderate copay for preferred brands
Tier 3 – High copay for non-preferred brands
Tier 4 – Highest copay for specialty drugs
Given their premium brand name status and specialty classification, most plans place Wegovy/Mounjaro in Tier 3 or 4 – meaning high out-of-pocket costs if approved.
Some plans cover semaglutide under Tier 2 however since its originally approved use was for diabetes.
Tier assignment is the first coverage hurdle but not the last. Even if not denied outright due to high tier status, additional criteria must be satisfied…
Step 2: Prior Authorization Requirement
Given extreme costs of specialty drugs, nearly all insurers add prior authorization requirements governing access. This means additional paperwork confirming clinical necessity based on criteria like:
- Diagnosis of obesity or overweight status plus weight-related illness
- Previous attempts losing weight through diet and exercise
- Prior trial and failure on older anti-obesity medications
- Lack of contraindications or safety concerns
Meeting these factors demonstrates medical need justifying the high costs to gain approval. Some plans have additional stipulations like requiring a nutritional consultation first or caps on length of use.
Prior authorization denials can be appealed internally or through external review. Added paperwork and patience is needed but many initial rejections do ultimately get overturned.
Step 3: Affordability Evaluation
For tier 3/4 drugs with prior authorization in place, the final hurdle is demonstrating ability to pay the still significant out-of-pocket costs. What constitutes “affordable” varies greatly between plans.
Self-funded employer health plans have the most leeway restricting access through special formularies.
Odds also depend on whether you have a copay discount program like a patient assistance card from the drug manufacturer.
Advocating with evidence why you need the medication and can manage costs and side effects can help influence the affordability review.
And there you have it – the key steps guiding insurance coverage decisions for newly approved weight medications like tirzepatide and semaglutide!
While the hassle of paperwork, appeals and reviews awaits, understanding this framework places the odds for approval in your favor. Partner with your doctor and remain persistent through the process.
Many indeed break through the barriers and receive insurance assistance affording these life-changing new obesity drugs.