Choosing Health Insurance Coverage If You’re Living with Obesity

SLIDE 1

Living with Obesity?

Quick tips for how to navigate health insurance coverage for obesity care

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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.

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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?

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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.

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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.

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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.

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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

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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

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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.

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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.