Does United Healthcare Cover Wegovy for Weight Loss?

Understanding health insurance coverage can be tough, especially when it comes to new treatments. One such option that has gained popularity for weight loss is Wegovy, a prescription medication that can help with obesity and related health conditions.

But the big question on many people’s minds is, “Does UHC pay for Wegovy for weight loss?” The short answer is yes, but the details are a bit more complicated. So let’s dive in and explore the coverage for Wegovy under United Healthcare.

What is Wegovy?

Wegovy (semaglutide) is a brand-name prescription drug designed for long-term weight management in adults with obesity or overweight. It’s for those who have at least one weight-related health issue, like high blood pressure, type 2 diabetes, or high cholesterol.

Wegovy uses a substance called semaglutide. It acts like a hormone (GLP-1) that helps control hunger and how much you eat by working on certain parts of the brain.

This mechanism of action helps reduce hunger, leading to a decrease in calorie consumption and, subsequently, weight loss.

Wegovy works differently from many weight loss drugs. It changes signals in the body that control hunger, offering a new way to fight obesity.

Who is Wegovy prescribed for?

Wegovy is specifically prescribed to individuals who meet the following criteria:

• Adults with Obesity: Those with a Body Mass Index (BMI) of 30 or higher.
• Overweight Adults with Weight-related Health Conditions: Adults with a BMI of 27 or higher and have at least one weight-related condition like type 2 diabetes, high blood pressure, or high cholesterol.
• Children with Severe Obesity: Children aged 12 and older with a BMI in the 95th percentile or higher.
• Long-term Weight Management: It is intended for patients seeking long-term weight management who have previously struggled with weight loss through diet and exercise alone.

Is Wegovy Covered by United Healthcare for Weight Loss?

Yes, United Healthcare does provide coverage for Wegovy for weight loss, although this comes with some conditions.

The coverage is only available for those whose medical profiles align with the FDA-approved uses of Wegovy—specifically, adults with obesity or overweight adults who have at least one weight-related health issue.

You can check your plan’s list of medicines to see what’s included and under what conditions. Basically, if Wegovy is really needed for your health and fits United Healthcare’s rules, there’s a good chance it will be covered.

Also Read: Does UHC Cover Ozempic for Weight Loss?

How Much Does Wegovy Cost With or Without Insurance?

Generally, without insurance, the cost of Wegovy can be quite high, around $1,350 for a 28-day supply. However, this cash price can be higher due to markups and dispensing fees. If you have insurance, the amount you pay may be significantly less.

For those with United Healthcare, the price might be a lot cheaper, based on their health plan details. Some plans might pay for the medicine fully, but others may ask for a small payment, which could be between $25 to a few hundred dollars every month.

What Are the Wegovy Prices Under United Healthcare Plans?

According to Novo Nordisk, the pharmaceutical company behind Wegovy, an impressive 80% of insured patients in the United States who are prescribed Wegovy typically pay less than $25 per month for the medication.

This treatment is affordable because big health insurance companies like United Healthcare cover it. This means more people who fit the medical needs can get the help they need to lose weight.

Eligibility Criteria for Wegovy

Treatments like Wegovy can be expensive, and not everyone is eligible for coverage under United Healthcare. To be eligible for coverage, you must meet the following requirements:

United Healthcare Eligibility for Wegovy Coverage:

• Must be an adult with a BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related health condition.
• Coverage is subject to approval based on the individual’s health plan and medical necessity as defined by United Healthcare.

Steps for Verifying Coverage:

1. Check the United Healthcare drug formulary on their website or contact customer service.
2. Understand the terms of your specific health plan, including any required step therapy or pre-authorization.

Consultation and Prescription Process:

• Schedule a consultation with a healthcare provider to discuss the suitability of Wegovy for your health condition.
• Obtain a prescription from your healthcare provider, ensuring it specifies the necessity for weight loss and related health conditions.

Costs and Co-payments:

• The specific cost or co-payment for Wegovy under United Healthcare plans can vary; confirm with your plan for exact details.
• Assistance programs may be available for eligible patients to help reduce the cost burden.

RELATED: Does Aetna Cover Wegovy for Weight Loss?

Factors that Determine Coverage

Several factors play a critical role in determining the extent of Wegovy coverage under United Healthcare plans. These include:

• Clinical Necessity: The prescription must align with FDA guidelines, indicating Wegovy as essential for the patient’s weight management.
• Plan Specifics: Different United Healthcare plans have varying levels of coverage, deductibles, and co-payments. Policyholders need to review their plan details closely.
• Prior Authorizations: Some United Healthcare plans require prior authorization for Wegovy. This process involves obtaining approval from the insurance provider before the medication is covered.
• Step Therapy: Sometimes, United Healthcare requires patients to try one or more specific medicines before they approve covering Wegovy.

Knowing these things can help patients and doctors figure out how to deal with insurance for Wegovy better.

Conclusion

In summary, obtaining Wegovy through United Healthcare can provide a cost-effective solution for many patients seeking help with weight management. However, eligibility and out-of-pocket costs vary depending on your specific health plan and medical needs.

By understanding the coverage requirements and consulting with healthcare providers, you can navigate your options to access this innovative treatment, potentially transforming your health and quality of life.

FAQ

Can I get United Healthcare to cover Wegovy if it’s not in my plan?

Yes, it’s possible for you to get United Healthcare to cover Wegovy even if it’s initially not included in your plan. Your healthcare provider may need to submit a formulary exception request on your behalf, providing evidence that Wegovy is medically necessary for your condition. If approved, you could receive coverage even if Wegovy isn’t listed on your plan’s formulary.

How do I know if my United Healthcare plan covers Wegovy?

To determine if your United Healthcare plan covers Wegovy, you should first review the drug formulary on the United Healthcare website or contact their customer service directly. This will provide you with the specific coverage details relevant to your plan.