With obesity rates continuing to climb in the United States, many people are looking for ways to lose weight and keep it off. One option that has become increasingly popular over the past decade is weight loss injections.
These injectable medications promote weight loss by suppressing appetite, increasing feelings of fullness, or altering how the body absorbs fat and calories.
But weight loss injections are prescription medications and can be expensive without insurance coverage. That leads many to wonder – does my health insurance plan cover these? Specifically, does Blue Cross Blue Shield cover weight loss injections?
Below we’ll explore common weight loss injections, typical health insurance coverage, Blue Cross Blue Shield’s policies, and alternative ways to reduce costs if your injections are not covered.
What Are Weight Loss Injections and How Do They Work?
Before diving into the insurance coverage question, let’s first explain exactly what weight loss injections are and provide an overview of some of the more popular options:
Saxenda
Saxenda is the brand name for the injectable weight loss medication liraglutide. It is an glucagon-like peptide-1 (GLP-1) receptor agonist, which means it mimics a hormone called GLP-1 that is released naturally by the body.
The way Saxenda promotes weight loss is by suppressing appetite and enhancing feelings of fullness. In clinical trials, people using Saxenda lost an average of 12 pounds over a year.
Contrave
Contrave is the brand name for the combination drug naltrexone/bupropion. It uses two medications that have been around for years treating other conditions – naltrexone for alcohol and opioid dependence and bupropion as an antidepressant.
Contrave works on areas of the brain involved in food cravings and eating habits to reduce appetite and increase the feeling of fullness.
Those taking Contrave for weight loss have shown 5% to 10% reductions in their body weight compared to placebo.
Wegovy
Another GLP-1 receptor agonist like Saxenda, Wegovy contains a higher dose of the drug semaglutide. Injected under the skin once-weekly, it helps people feel more satisfied after meals and desire fewer between meal snacks.
In clinical trials, most patients taking Wegovy lost 15% or more body weight over 68 weeks using the medication along with improved diet and increased physical activity.
So in summary, weight loss injections like Saxenda, Contrave or Wegovy use pharmacological compounds to alter appetite signaling in the brain or impact nutrient absorption to lower calorie intake and jumpstart weight loss.
When combined with lifestyle changes, injections can enhance weight loss outcomes for some people struggling with obesity.
Does Health Insurance Typically Cover Weight Loss Injections?
Now that we understand what weight loss injections are, we can dive into the key question – will health insurance cover these prescription medications?
The short answer is typically no – most health insurance plans do not cover weight loss treatments, including newer injectable drugs like Saxenda or Wegovy.
There are a few reasons for this:
Labeled as Lifestyle Drugs
First, weight loss medications are still primarily categorized as “lifestyle drugs” rather than medically necessary treatments. In other words, losing weight is generally viewed as elective rather than required for health reasons (although this perception is starting to shift).
Since injections like Saxenda and Contrave are not correcting any biological deficiency per se, insurers leave them off covered drug formularies along with other drugs that enhance lifestyle or performance.
Varying Medical Necessity
Secondly, insurers point to a lack of clear medical necessity criteria for prescribing weight loss medications – criteria that would justify why Patient A needs Saxenda for their health, but Patient B does not.
For example, what BMI or health marker should dictate prescription of Saxenda? Without standardized guidelines, the “need” for weight loss drugs can seem subjective or arbitrary from the insurer standpoint.
Concerns Over Misuse
Finally, there may be concerns over misuse or over-utilization if weight loss injections were universally covered. Insurers aim to control medication costs which could quickly escalate if large swaths of members were suddenly approved for $1000+ per month injectable regimens.
As a result of these primary objections – the labeling as a lifestyle treatment, lack of clear medical necessity thresholds, and concerns over costs – most health plans categorize weight loss injections as exclusions requiring patients to pay full out-of-pocket costs.
What is Blue Cross Blue Shield’s Stance?
Now we can specifically address the question of Blue Cross Blue Shield’s coverage policies for weight loss injections like Saxenda or Ozempic.
As background, Blue Cross Blue Shield (BCBS) covers 1 in 3 Americans across all 50 states through a variety of individual health plans or employer-based group plans. But what coverage varies is managed on more localized state and regional levels.
This means there is no uniform national policy on what BCBS covers regarding weight loss treatments or medications. General trends do emerge however that apply to most BCBS health plans:
Labeled Lifestyle Medications
Echoing the perspective of health insurers nationally, most Blue Cross Blue Shield plans classify injectable weight loss treatments as lifestyle enhancement drugs rather than medically necessary. This categorization puts them outside of covered pharmacy benefits.
Select Use With Prior Authorization
Some BCBS plans will cover Saxenda, Wegovy or Contrave with prior authorization requirements – meaning additional medical documentation must be submitted and approved demonstrating patient need before coverage applies.
For example, plans may require proof the member meets certain BMI thresholds (e.g. BMI over 30) or has obesity-related conditions impacted by weight loss such as diabetes or hypertension. But prior authorization is inconsistently implemented across regions.
Off-Label Excluded
There are also often restrictions limiting coverage only to FDA-approved indications. For example, if Ozempic is prescribed off-label for weight loss instead of its on-label use for Type 2 diabetes, BCBS may deny coverage.
The same goes for Wegovy which now has FDA approval for chronic weight management but often faces coverage denials if prescribed off-label for weight loss specifically.
Employer Plan Exceptions
Some subscribers under BCBS employer group plans report coverage for Saxenda or other weight loss drugs depending on what that particular employer chooses to include.
These members likely fall under plan provisions negotiated by their company around medication coverage. But this is not the norm.
So in summary, while some variability exists stemming primarily from prior authorization rules and employer plan exceptions in certain cases, the predominant stance among Blue Cross Blue Shield insurers does not include coverage of weight loss medications or injections in core pharmacy benefits. Like other major insurers, they are largely deemed lifestyle treatments versus medically essential.
Alternative Ways To Reduce Costs of Weight Loss Injections
Since securing insurance coverage of prescription weight loss injections through Blue Cross Blue Shield or other major medical insurers is very difficult, how can you cut costs if paying full retail price?
Here are some money-saving options to make these medications more affordable even without health plan coverage:
Apply for Copay Card Discounts
Pharmaceutical manufacturers like Novo Nordisk (makes Saxenda and Wegovy) or VIVUS (makes Contrave) offer copay discount programs that can lower your out of pocket costs for weight loss injections by up to $200 per month.
Reducing your copay responsibility makes paying cash price more feasible.
Use GoodRx Coupons
Another way to get discounts on weight loss drugs is prescription coupon programs like GoodRx. Enter your prescription and they provide free coupons that can be used whether or not you have insurance coverage.
Typical savings are 10-15% but can reach up to 80% off cash price.
Submit Claims to FSA Accounts
If you signed up for a flexible spending account (FSA) either independently or through your employer, you can pay for weight loss medications out of pre-tax dollars. FSA funds can be applied toward prescriptions whether insurance is covering them or not.
Enroll in Payment Plans
Don’t have over $1000 to cover the cash price all at once? Programs like Ready Set Pay allow you to enroll in fixed payment plans to cover your prescription in more affordable monthly installments over 6 or 12 months rather than a single upfront cost.
The Bottom Line – Limited BCBS Coverage, But Savings Options Available
In the majority of cases, Blue Cross Blue Shield health plans do not include benefits covering weight loss injections or medications used to promote fat or calorie absorption.
As “lifestyle” pharmaceuticals without clear universally-accepted medical necessity criteria, drugs like Saxenda, Ozempic or Wegovy when prescribed for obesity. Pre-authorization exceptions exist but are inconsistently implemented.
For most BCBC subscribers, weight loss injections will be 100% out-of-pocket costs unless an employer has special provisions enhancing covered pharmacy benefits.
But don’t be discouraged. There are more and more resources like copay cards and prescription coupons that make paying cash price for weight loss medications affordable. Just be prepared for the likelihood that your core insurance will not apply.
So in summary – verify if exceptions exist under your specific BCBS plan, but otherwise anticipate covering full retail costs for weight loss drugs offset by discounts. Achieving significant weight reduction to improve your health is worth the investment!
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