A lot of people are looking to use weight loss or diabetes medications, like Ozempic (semaglutide), Wegovy (semaglutide), Mounjaro (tirzepatide), or Zepbound (tirzepatide). If you’re one of them, it’s important to understand how insurance coverage works for these meds and how a healthcare provider can help you navigate the process.
These medications aren’t automatically covered by insurance. Instead, insurance companies require a prior authorization (PA) before they give you coverage. Your healthcare provider can help you with the necessary steps of getting a PA through your insurance company.
Have a provider on Klarity Health help you navigate the PA process
Get StartedThis article covers how providers on the Klarity Health platform can work with you on the process to help you secure insurance coverage for your weight loss treatment.
1. Making sure you meet the criteria
Before trying to get coverage for a weight-loss medication, you want to understand the criteria for taking them and if you meet those criteria.
Criteria for prescription weight loss medications are determined when the U.S. Food and Drug Administration (FDA) gives the medication approval. While drugs can be legally prescribed off-label (for a use they’re not FDA approved for), an insurer isn’t likely to approve a PA for an off-label use or if you don’t meet the FDA’s established criteria.
A provider can help you determine if you meet the FDA’s criteria. They can assess whether you have the required body mass index (BMI) (aka weight) and any related comorbidities (like high blood pressure, type 2 diabetes, heart problems, or high cholesterol) if applicable. They’ll also evaluate whether or not a medication like Ozempic or Wegovy is medically necessary for your needs.
For example, if you’re interested in insurance coverage for Wegovy, you need to:
- Have obesity, which is a BMI of 30 or more
- Be medically overweight with a BMI of 27 or more and at least 1 weight-related condition
A provider can document that you meet these criteria in a letter to your insurance company to show that Wegovi is a medical necessity medication for you.
2. Creating proper documentation of your health
Providers on Klarity Health can help ensure that all the necessary documentation is submitted to your insurance company and ensure the following is included:
- Your BMI (a measure of body fat based on height and weight)
- Comorbidities, such as type 1 or 2 diabetes, sleep apnea, high blood pressure, heart problems, or high cholesterol
- Past treatments you’ve tried, including whether prior medications for weight loss or type 2 diabetes
- Your A1c level for medications like Ozempic and Mounjaro that are FDA-approved for lowering blood sugar in people with type 2 diabetes and not weight loss
This documentation is important to show that the medication is necessary for your health.
3. Filing for prior authorization (PA)
Once all the information is in place, your provider can submit a prior authorization (PA) request to your insurance company. This starts the official process where the insurance reviews your PA request and determines if they will cover the medication.
If you’re seeing a provider on Klarity Health, they’ll streamline this process and ensure your request is filled out correctly and submitted without any errors.
Here’s where your provider on Klarity Health adds value:
- Accurate diagnosis codes: Your provider makes sure to use the right codes to ensure your request isn’t denied due to simple coding errors.
- Medical necessity: If your insurance needs more proof, your provider can provide documentation of your condition and treatment history to strengthen the case for coverage.
4. Handling PA denials and appeals
Even with a well-documented PA request, insurance companies may still deny coverage. This can happen for a variety of reasons, including:
- Incorrect diagnosis codes
- Missing information
- Your insurance plan’s restrictions
If your PA is denied, providers on Klarity Health will work with you to file an appeal or request an exception, especially for medications that aren’t on your insurance plan’s formulary.
For example, if your insurance plan initially denies coverage for Wegovy, your provider can submit an appeal with additional documentation or try for a formulary exception.
Don’t fight your insurance company alone
Get the help of a provider on Klarity Health
The value of working with a provider on Klarity Health
Navigating insurance coverage on your own can be complicated and time-consuming. But when you work with a provider on Klarity Health, they take the guesswork out of the process. Experienced providers on Klarity Health understand how insurance works and what it takes to get medications like Ozempic and Wegovy approved.
By booking an appointment with a provider on Klarity Health, you:
- Get a personalized evaluation of your weight loss or diabetes treatment needs
- Have a healthcare professional handle the details of the prior authorization process for you
- Receive ongoing support for any challenges with denials or needed appeals
The goal of Klarity Health and the providers on Klarity Health is to help you get the medication you need for your weight loss journey with as little hassle as possible.
Ready to get started?
Book a session with one of the experienced, caring providers on Klarity Health today to discuss your weight loss or diabetes treatment goals and how they can help you secure the insurance coverage you need for medications.
Additional reading
Appointments are generally available within 24 hours. Free initial consultations are available only with select providers. Prescriptions, particularly for controlled substances, may require an in-person evaluation depending on the state of residence and current federal regulations.
The information provided in this article is for educational purposes only and should not be construed as medical advice. Always seek the guidance of a qualified healthcare professional with any questions or concerns you have regarding your health. Providers on Klarity Health are independent practitioners with clinical autonomy. Nothing in this article is intended to diagnose or treat any condition, including guaranteeing prescription medication of any kind or dosage. Not all providers on Klarity Health prescribe all medications, particularly medications that are controlled substances.
If you’re having a mental health crisis or experiencing a psychiatric emergency, it’s crucial to seek immediate help from a mental healthcare professional, such as a psychiatrist, psychologist, or therapist. You can also call your local emergency services, visit your nearest emergency room, or contact a crisis hotline, such as the National Suicide Prevention Lifeline, by calling or texting 988 or dialing the Lifeline’s previous phone number, 1-800-273-TALK (1-800-273-8255) in the U.S.
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