Approximately 4 out of 10 American adults live with obesity, a medical condition that can cause serious health problems such as heart disease, diabetes and cancer.
There are treatments, like weight loss medications and surgery, that can help, but they can also be expensive. For example, medication prescribed for weight loss can cost around $1,000 per month and weight loss surgery can cost as much as $30,000 without any help from insurance.
Since obesity is a disease, it’s a no brainer that health insurance companies should pay for obesity treatment. But that’s not a given. If you live with obesity and want to know if your care will be covered — and how much it’ll cost you — here are six steps you can take to find out:
1. Look for policy exclusions or inclusions.
Most health plans won’t cover certain services. Check for “exclusions” or “expenses not covered” related to weight loss treatment. If you find weight loss surgery, medications or other programs on this exclusion list, the plan won’t cover them.
On the other hand, some policies do include treatment for obesity for people who meet the criteria. Look for “inclusions” or “covered expenses.”
2. Is the drug you need covered?
Check the plan’s drug list, sometimes called “the preferred drug list” or “formulary.” You may have to dig around online to find it or call the plan to get it. Make sure you’re looking at the right list for the specific plan you’re considering. The same insurance company can have different lists for different plans.
Look for the specific drug in the formulation (pills, injection, etc.) you need. If a drug has different forms or versions, not all are necessarily covered.
Note that plans can change the drug list mid-year, though they’ll have to give you advance notice of changes that affect you.
3. What tier is the medicine you need?
Health plans organize medications by tier. Each tier has different costs (e.g., copayments or coinsurance).
Note which tier your drug is in. Then, check the policy to find your costs for that tier. Usually, generic drugs have lower copayments. Brand-name and more expensive drugs are often higher tiers and cost more.
4. What rules might apply to your medication or surgery?
Health plans often apply certain rules before they’ll cover some drugs or services. These can include:
- Quantity limits: Health plans can limit the quantity of medicine you can get within a specific time period.
- Step therapy: Plans may require you to try a lower-cost drug and show that it doesn’t work for you before they’ll pay for the drug you need. When you join a new plan, you may have to go through step therapy even if you’re already taking the drug.
- Prior authorization: Health plans can require that you get approval from them before they’ll cover a drug or service. There’s no guarantee they’ll grant prior authorization.
Read: What You Need to Know About Prior Authorization >>
- Other requirements: For weight loss surgery, you’ll likely have to show that the surgery is medically necessary, and you may have to complete a supervised diet program and/or psychological evaluation before insurance will cover it.
5. What will your costs be?
Consider the different costs you could be responsible for, including:
- Copayments: The fee you pay for each service will vary. Each time you fill a prescription or have a procedure, you’ll likely have to pay something.
- Coinsurance: Insurers sometimes make you pay a percentage of the costs of specific services or drugs.
- Deductible: If your plan has a deductible, you’ll have to pay the full cost of a drug or service until you’ve satisfied the deductible. Pay special attention to the design of your deductible. Some plans have a separate deductible just for prescriptions.
- Out-of-pocket maximum: There is often a limit to the total amount you’ll have to pay for covered services out of your own pocket. Once you reach that cap, the plan should pick up the full cost of covered services. But you could be on the hook for cost-sharing until then.
Read: Health Insurance 101: Understanding Health Insurance Terms >>
6. Is your healthcare provider or facility covered?
Health plans usually set up a network of participating healthcare providers (HCPs). Even if a specific drug is covered, you’ll also need the HCP who prescribes it to be in the plan’s network. Check all your HCPs in the directory of participating providers before you sign up for any health insurance plan.
Figuring out what will be covered can be tricky. If you have any doubt — or even if you feel pretty sure — contact the health plan to confirm. If you get health insurance through your job, your benefits representative can also help.
This educational resource was created with support from Eli Lilly and Company.
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