Choosing Health Insurance Coverage If You’re Living with Obesity
Quick tips for how to navigate health insurance coverage for obesity care
Dec 04, 2023
Dec 18, 2023
Your Care
Deb Gordon
Deborah D. Gordon has spent her career trying to level the playing field for healthcare consumers. She is co-founder of Umbra Health Advocacy, a marketplace for patient advocacy services, and co-director of the Alliance of Professional Health Advocates, the premiere membership organization for independent advocates. She is the author of "The Health Care Consumer's Manifesto: How to Get the Most for Your Money," based on consumer research she conducted as a senior fellow in the Harvard Kennedy School's Mossavar-Rahmani Center for Business and Government. Deb previously spent more than two decades in healthcare leadership roles, including chief marketing officer for a Massachusetts health plan and CEO of a health technology company. Deb is an Aspen Institute Health Innovators Fellow, an Eisenhower Fellow and a Boston Business Journal 40-under-40 honoree. Her contributions have appeared in JAMA Network Open, the Harvard Business Review blog, USA Today, RealClear Politics, The Hill and Managed Care Magazine. She earned a BA in bioethics from Brown University and an MBA with distinction from Harvard Business School.
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SLIDE 1
Living with Obesity?
Quick tips for how to navigate health insurance coverage for obesity care
SLIDE 2
Obesity is a disease that affects 4 out of 10 American adults.
Medication, surgery, diet and exercise programs, and working with mental health professionals can help people lose weight but can be expensive.
Will insurance cover these costs? Here’s how to find out.
SLIDE 3
Health insurance plans don’t cover everything. Some services are specifically not covered.
Check for exclusions and inclusions: Does your policy say they will or won’t cover obesity treatments such as medications, surgery, obesity specialists or nutrition and exercise programs?
SLIDE 4
Check the drug list (sometimes called “formulary”). Look at the type (e.g., capsule vs. injection), dosing and brand. Some versions may not be covered.
The list can change any time. If the plan stops covering your medication, they’ll give you advance notice. You may be able to appeal.
SLIDE 5
A tiered formulary divides drugs into groups based on cost.
Lower tiers = lower costs
Higher tiers = higher costs and may have more restrictions or hurdles to jump through
Each plan is different. Be sure to check the policy documents for your plan to make sure your medications are covered.
SLIDE 6
Plans may have extra requirements for some medications:
- Quantity limits: You can only get a certain amount of medicine at a time.
- Step therapy: You have to try and fail other medicines before they’ll cover your drug.
- Prior authorization: You have to request and get approval in advance.
SLIDE 7
Before weight-loss surgery, you may have to meet requirements. These can include:
- Medical necessity: Show that weight-loss surgery is key to your health
- Diet program: Complete a supervised diet
- Psychological evaluation: Show that you’re emotionally ready for surgery and related changes
SLIDE 8
Estimate your costs:
- Deductible: The amount you pay before insurance starts to pay
- Copayments: Your fee for a prescription or service
- Coinsurance: A percentage of costs for medications or services that you pay after meeting your deductible
- Out-of-pocket maximum: The most you’ll pay for covered services in a plan year
SLIDE 9
Is your healthcare provider (HCP) covered?
Check the provider directory to see if the plan covers your HCP or facility.
Some plans let you go outside the network if you pay more. Some plans (like HMOs) pay nothing unless you see a participating provider.
SLIDE 10
Don’t get stuck without coverage for treatment you need. Arm yourself with information.
When in doubt, contact the health plan to confirm what’s covered and what it’ll cost you.
If you have health insurance through a job, ask HR for help.
This educational resource was created with support from Eli Lilly and Company.
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