Losing weight is on the mind of so many Americans these days. Obesity rates continue climbing each year, now impacting over 40% of adults.
With this comes desires to improve health and wellbeing through shedding excess pounds.
Weight loss medications provide an appealing avenue to help accelerate weight loss results.
But health insurance coverage varies greatly on these types of drugs.
This leaves many wondering – does Anthem cover weight loss medications?
Anthem BCBS (Blue Cross Blue Shield) offers health insurance plans to individuals and employers across 14 states.
With millions of members, Anthem aims to make healthcare accessible and affordable. Like other insurers, Anthem evaluates weight loss drugs differently than other prescription medications.
Coverage decisions depend on the specific medication, the member’s health plan, and whether a doctor deems it medically necessary.
Background on Weight Loss Medications
Prescription medications for losing weight work by suppressing appetite, increasing satiety, blocking fat absorption, or altering hormones related to weight regulation.
Some over-the-counter supplements also claim to boost weight loss, although generally with less powerful effects.
Common prescription weight loss drugs include:
- Phentermine – Appetite suppressant used short-term for rapid weight loss.
- Orlistat (Xenical, Alli) – Blocks absorption of dietary fats to promote weight loss.
- Liraglutide (Saxenda) – GLP-1 inhibitor injection to reduce hunger and increase satiety.
- Naltrexone/bupropion (Contrave) – Combination pill to reduce appetite and food cravings.
- Phentermine/topiramate (Qsymia) – Appetite suppressant mix also altering taste for foods.
These medications work in different ways, such as acting on hunger-regulating hormones or limiting fat absorption. But all aim to create the calorie deficit needed for clinically significant weight loss.
Over-the-counter supplements like garcinia cambogia or raspberry ketones are also marketed for weight loss but lack strong clinical evidence.
For those with obesity or at high risk for weight-related diseases, prescription medications tend to produce better health improvements.
Anthem Health Insurance Coverage
Anthem BCBS provides group health insurance plans sponsored by employers, as well as individual and family plans directly to consumers.
They have PPO, HMO, POS, HSA, and HRA plans spanning 14 states. With 80 million members, Anthem is the 2nd largest health insurer in the U.S.
But despite their size and prevalence, Anthem does not take a blanket approach to covering weight loss drugs.
Each medication goes through an evidence-based review to construct pharmacy policy and formulary placement. From there, coverage decisions get made at the individual health plan level.
Certain employer-based plans may even negotiate custom pharmacy benefits.
This leaves lots of variability around whether someone’s specific Anthem policy covers weight loss medications – and if so, which ones and with what restrictions. Several key factors influence this coverage.
Factors that Impact Coverage
Anthem considers weight loss drugs differently than other prescription medications.
Unlike drugs treating acute conditions like infections, insurers view obesity drugs as targeting lifestyle issues.
And unlike chronic disease medications, they don’t see weight medications as medically necessary in all cases.
Here are the main variables that determine if Anthem covers specific weight loss drugs:
Type of Health Plan
Anthem policies range from higher coverage to more restrictive in terms of drug benefits:
- PPO plans tend to be the most generous, offering copays for a wide range of medications once deductibles are met. They will cover weight loss drugs more readily if deemed medically necessary.
- HMO and EPO plans feature set copays for prescriptions but utilize more limited formularies, so may exclude weight loss medications altogether or impose more coverage hurdles.
- HSA and HRA plans won’t cover weight loss drugs as a general rule until someone meets their large deductible. Doctors may still prescribe for medical necessity.
In all cases, employer-based plans have more flexibility than individual state marketplace plans sold by Anthem.
Company plans may cover more medication options, pursue less prior authorization requirements, or offer exceptions for medical need.
FDA Approval Status
Currently, only 3 prescription weight loss medications have formal FDA approval specifically for long-term weight management:
- Xenical (orlistat)
- Contrave (naltrexone-bupropion)
- Saxenda (liraglutide)
As these met clinical trial efficacy and safety standards for obesity treatment, insurance plans like Anthem get more reassurance on covering them long-term.
The other common weight loss drugs only have short-term FDA approval for help losing weight:
- Phentermine (up to 12 weeks)
- Qsymia (phentermine plus topiramate)
Without data on safe and effective use beyond a few months, Anthem does not cover these medications for ongoing obesity past short time windows without extenuating circumstances.
Medical Necessity
In line with most insurance carriers, Anthem wants prescribing providers to demonstrate medical necessity for covering weight loss drugs long-term.
To meet medical necessity criteria, a person’s doctor must document:
- Diagnosed obesity – Usually indicated by BMI over 30 or at least 27 with weight-related health conditions. Providers should note if patients meet criteria for obesity classes I, II or III.
- Failure to lose weight through other means first – Documentation must reflect adequate attempts to lose weight through increased physical activity and medical nutrition therapy without success.
- High health risks requiring weight reduction – Such as high blood pressure, diabetes or prediabetes, high cholesterol, sleep apnea, heart disease, stroke risk, etc. Improved health markers rely on losing excess weight.
With this level of evidence, Anthem gets reassurance of appropriate use cases with health benefits outweighing risks.
It supports covering medication costs as medically necessary, rather than using drugs for cosmetic reasons.
Formulary Listing
Beyond medical need, Anthem also bases prescription coverage on how they categorize medications based on efficacy, safety, and cost:
- Tier 1 – Lowest copay, most cost effective options
- Tier 2 – Mid-range copay for brand name and other common choices
- Tier 3 – Highest copay for newest, expensive brands or options with generic alternatives
Anthem places both prescription Xenical and over-the-counter Alli Orlistat in Tier 1, making them the most affordable weight loss medication option.
Saxenda injectables fall into higher tiers due to expense.
Where Anthem positions Contrave and other drugs varies between plans.
Information on Claiming Coverage
Wondering if your specific Anthem plan covers a particular weight loss medication? Here is the process to find out:
1. Check your plan’s formulary list – This master list notes which prescription medications fall into different copay tiers.
It will indicate which obesity drugs are covered under what conditions.
2. Speak with your doctor – Share if a weight loss drug interests you and have your physician submit a prior authorization request to Anthem if drug is not outright included on formulary.
This requires documenting obesity diagnosis, attempts at lifestyle changes first, health risks indicating need for weight loss, and rationale for medication choice.
3. Confirm prior authorization – Assuming medical necessity gets established, Anthem will approve limited coverage span (often 6 months to 1 year) requiring additional renewal if weight loss milestones achieve.
4. Appeal any denials – If prior authorization gets denied, your doctor can appeal the decision by sending additional clinical documentation.
An independent third party review may overturn the denial.
When using this process, individual exceptions can get made even if broad policy excludes coverage for weight loss medications.
Self-advocacy and persistence pays off.
Key Takeaways
- Anthem health plans do not universally cover weight loss drugs, unlike medications for most acute and chronic health conditions.
- Coverage decisions happen at the individual health policy level based on type of insurance plan, FDA approval status for the specific medication, whether it meets medical necessity thresholds, and tier list ranking.
- Xenical, Contrave and Saxenda have the best shot at approval since they have formal FDA obesity indications.
- Drugs like phentermine likely won’t get covered for long-term use.
- To receive coverage, providers need to thoroughly document obesity diagnosis, failed weight loss attempts through diet and exercise changes first, high risk for weight-related diseases requiring loss, and rationale behind medication choice.
- Be prepared to appeal any claim denials by sending additional clinical details that satisfy medical necessity requirements.
- Securing coverage takes diligence but pays off.
Conclusion
While historically hesitant to cover weight-related treatments, health insurance companies like Anthem make more exceptions for clinically proven and FDA-approved weight loss medications today.
This comes with proper diagnoses and documentation from doctors focused on improving patient health, not just