Have You Or a Loved one received a Wegovy Health Insurance Denial? We Can Help.
Wegovy is a medication for obese and chronically overweight individuals. Approved by the FDA in June 2021, both adults and children over the age of 12 take the medication. Oftentimes health insurers deny Wegovy. Not only is it expensive, but the Affordable Care Act doesn’t require insurers to cover obesity medications. This page provides an overview of Wegovy and health insurance claims. We cover how health insurers evaluate Wegovy’s medical necessity. And we give you information on what to do if you receive a Wegovy health insurance denial. If you receive a Wegovy health insurance denial, contact the Law Offices of Scott Glovsky. We understand how insurers operate and have been helping policyholders overturn denied claims for over two decades.
What is Wegovy?
Wegovy, containing semaglutide, is a medication for weight management typically given to obese or chronically overweight patients with at least one weight-related condition. These conditions include type 2 diabetes, high blood pressure and high cholesterol. Wegovy is a glucagon-like peptide-1 (GLP-1) receptor agonist that works by increasing the release of insulin and decreasing the release of glucagon. Doing so helps regulate glucose levels and reduce food intake. In other words, Wegovy reduces hunger and increases feelings of fullness, which leads to decreased food intake and ultimately weight loss. Like other weight management drugs, Wegovy should be combined with a reduced calorie diet and increased physical activity. Sometimes Wegovy is given to people who cannot lose weight through diet and exercise alone.
In a clinical trial, participants taking Wegovy over a 68-week period lost, on average, 15% of their body weight. In addition to Wegovy, these participants also exercised more and ate fewer calories.
By promoting weight loss, Wegovy may help improve obesity-related health conditions like high blood pressure, heart disease, and sleep apnea. It may also improve overall health, increase energy levels, and improve quality of life.
Wegovy is manufactured by Novo Nordisk. The same pharmaceutical company makes Ozempic. Ozempic also contains semaglutide, but it is not FDA approved for weight loss. (It is FDA approved for type 2 diabetes.) That said, doctors sometimes prescribe Ozempic off-label for weight loss.
But at $1,345 to over $1,700+ per month, Wegovy is expensive. Of course, a person’s cost depends on several factors including potential insurance coverage and dose.
What is Obesity?
Obesity is a chronic condition characterized by excessive accumulation of body fat, resulting in an unhealthy weight. It increases the risk of certain health problems including heart disease, type 2 diabetes, sleep apnea and certain cancers. Obesity is determined by Body Mass Index (BMI), which is calculated by dividing an individual’s weight in kilograms by the square of their height in meters. A BMI greater than or equal to 30 is considered obese. (A BMI 25 ≤ 30 is overweight.)
Unfortunately, many Americans are overweight or obese. 30.7% of American adults are overweight and 42% are obese. And almost 20% of kids 2 to 19 are obese. And a study published in March 2023 that evaluated young adults aged 20 to 44 from 2009 to 2020 found that the prevalence of diabetes increased from 3% to 4.1% and the incidence of obesity grew from 32.7% to 40.9%.
Who Can Take Wegovy?
Wegovy is approved for use in adults with a body mass index (BMI) of 30 or higher, or a BMI of 27 or higher with at least one weight-related health condition such as high blood pressure or type 2 diabetes. The medication is also approved for children 12 and older with a BMI at or greater than the 95th percentile standardized for age and sex.
How is Wegovy Administered?
Wegovy is an injection administered under the skin once a week. It is usually given in the abdomen, thigh, or upper arm. The FDA approved dose is 2.4 mg, and Wegovy comes in 5 different doses – 0.25 mg, 1 mg, 1.7 mg, and 2.4 mg. A specific dose may vary depending on a patient’s needs and response to treatment.
How Does Wegovy Compare With Ozempic and Mounjaro?
All three of these drugs help type 2 diabetics and include GLP-1 receptor agonist. The differences include what they were FDA-approved for, their formulations, their doses, and their costs.
Wegovy and Ozempic
Novo Nordisc manufactures both Wegovy and Ozempic. Both medications are glucagon-like peptide-1 (GLP-1) receptor agonist weekly injections with semaglutide as their active ingredient. While Wegovy’s main dose is 2.4 mg weekly, Ozempic’s primary dose is 2 mg weekly. In terms of cost, in 2023, Wegovy’s list price is $1,349/package and Ozempic’s list price is $892 for a 2 mg pen.Of course in 2021, Wegovy was FDA-approved in 2021 for obesity and chronic overweight with at least one weight-related health issue such as type 2 diabetes or high blood pressure. And in 2017, Ozempic received FDA-approval for type 2 diabetes and to help with cardiovascular issues.
Although they share the same active ingredient, Ozempic is often prescribed instead of Wegovy for weight loss because it is cheaper, more widely available, and more often approved by insurers because it is FDA-approved for diabetes. And health insurance policies under the Affordable Care Act aren’t required to cover obesity drugs or surgeries.
Mounjaro
Mounjaro (Tirzepatide), on the other hand, has a different active ingredient. Unlike Ozempic and Wegovy that include the active semaglutide, Mounjaro contains tirzepatide. Mounjaro is the first and only dual glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonist. Mounjaro received FDA-approval in May 2022 to improve glycemic control in adults with type 2 diabetes. Months later, in October 2022, Mounjaro received a fast track FDA review as a treatment for obesity. Given that the Phase 3 clinical trial is due to end in April 2023, Mounjaro might be approved for obesity and weight loss sometime in 2023.
Weight Loss
When it comes to weight loss, Mounjaro has the edge. While Wegovy clinical trial participants lost, on average, 15% of their body weight, individuals in the Mounjaro clinical trial who took the highest dose lost up to 22.5% of their body weight.
Do Insurance Companies Cover Wegovy?
Health insurance coverage for Wegovy varies across insurers and disease types. The Affordable Care Act does not mandate health insurers to cover obesity-related surgeries or medications. And Wegovy is not approved to treat diabetes. Medicaid coverage is state-specific so you can check your state’s plan. Medicare (federal health insurance for adults 65+) does not cover medications for obesity. That said, certain Medigap and Medicare Advantage plans for retired individuals do cover Wegovy. The VA covers some drugs for obesity.
Coverage policies differ among major commercial insurance providers such as Cigna, Blue Shield, Kaiser, Anthem Blue Cross, Aetna, UnitedHealthcare, Oscar, and Health Net. Their coverage depends on several factors, including the specific insurance policy, medical necessity determination, and individual health circumstances. Commercial private health insurance companies typically approve Wegovy claims when they deem them medically necessary. That said, as media outlets like 60 Minutes reveal, getting approval can be difficult even when many alternatives failed.
Is Wegovy Considered Medically Necessary or Medically Beneficial?
A prior authorization is usually required prior to covering Wegovy. This means that the insurer deems the drug medically necessary for the patient’s condition. However, the process of obtaining prior authorization can be challenging, depending on the insurer’s requirements.
If the insurer doesn’t consider Wegovy medically necessary, it will likely deny coverage for the medication. Although the drug may have medical benefits and be medically beneficial, this doesn’t necessarily mean the insurer considers it medically necessary. In fact, oftentimes insurers want policyholders to try less expensive options first.
Insurers frequently require step therapy when alternative drugs are available. This type of prior authorization requires patients to try a less expensive or generic drug before being allowed to access the prescribed drug. In most cases, a 60-day trial is required before the necessity of the preferred drug is re-evaluated. Because Wegovy is an expensive option, insurance companies may require step therapy for claim approval. Unfortunately, this process can be detrimental to patient health, as the trial of alternative drugs can prolong the symptoms being treated. Without prior authorization, patients may be unable to access the drugs prescribed by their doctors.
How Do Insurance Companies Assess Wegovy Coverage Requests?
Health insurers evaluate coverage requests based on internal pharmacy or medical policies. Upon FDA approval of drugs such as Wegovy, health insurance companies conduct research to establish clinical policies that govern medical necessity decisions. These policies are reviewed and evaluated by a group of external physicians, however, their judgment may be influenced by external factors such as financial incentives or the possibility of working for the insurance company. This can result in the approval of excessively strict internal policies.
Health insurance providers assess claims by determining if a drug is deemed medically necessary or considered experimental or investigational. Rigid policies can lead to discrepancies between what healthcare providers view as necessary and what insurance companies deem so. Medical professionals base their treatment decisions on peer-reviewed literature and personal experience, which often highlight safe and effective options for various patient circumstances. These peer-reviewed sources draw from scientific evidence and research to inform their findings.
Is Wegovy Considered Medically Necessary?
Health insurance providers assess the medical necessity of drugs such as Wegovy. If deemed not medically necessary, it’s referred to as experimental or investigational. There can be several reasons for this classification, including internal policy definitions, inconclusive evidence of its effectiveness, lack of FDA approval, the availability of alternate drugs that are safe and effective, or the drug’s inability to enhance health outcomes.
There can be inconsistencies in how health insurance companies categorize drugs, with one considering a medication medically necessary, while another deeming it experimental or investigational. The criteria used to classify drugs can differ among insurers and are subject to interpretation. Variations in patient responses to the same drug also impact the claims approval process. These decisions are dependent on the specific language outlined in the contract, which can be subjective, leading to complexities.
What Duties Does Your Insurance Company Have When It Receives Policyholder Claims?
Your insurance company must review your submitted claims and approve or deny them. In making its decision, it must thoroughly investigate each claim. Part of its investigation includes researching all possible reasons why the medication or treatment could be medically necessary. Of course, it must respond to each claim promptly and have qualified medical authorities review each claim.
What Can You Do If You Receive a Wegovy Health Insurance Denial?
You can appeal the Wegovy health insurance denial. Before you do, however, understand if you have an ERISA or non-ERISA plan. Why? Because the path you follow may be different based on your plan type. What is ERISA? ERISA is the Employment Retirement Income Security Act of 1974. Many people aren’t sure what type of plan they have. You can ask your health insurance plan administrator or you can call your health insurer directly.
A general rule of thumb is that private employers usually have ERISA insurance plans. The following are exceptions to this rule of thumb:
- government employers since they aren’t private
- religious organizations such as mosques, churches and synagogues
- business plans that only insure business owners and their families
- family and individual plans obtained from Covered California
- family and individual plans bought directly from private insurance companies like Anthem Blue Cross or Blue Shield of California
- many plans for Native American entities or tribes
If your plan falls under ERISA, file an appeal since your options are more limited. Speaking with an experienced health insurance lawyer before filing is helpful. Discover more about the appeals process for ERISA policies here. If your plan does not fall under ERISA, you have more options. First, know why your claim was denied. Non-ERISA plan members can learn more here.
Contact Our Offices if You Receive A Wegovy Health Insurance Denial
For over 20 years, the Law Offices of Scott Glovsky has been a champion for individuals who have suffered injuries or been subjected to unjust business practices. With a focus on health insurance bad faith, catastrophic personal injury, sexual abuse, and consumer-related legal issues, our firm gets justice for our clients and holds those responsible accountable for their actions.
