GLP-1 Medication: Insurance Coverage Checklist & Guide

GLP-1 Medication: Insurance Coverage Checklist & Guide

What Is a GLP-1 Medication?

GLP-1 medications (such as Ozempic, Wegovy, Mounjaro, Zepbound, and Rybelsus) are FDA-approved treatments for conditions including type 2 diabetes, obesity, cardiovascular disease risk reduction, obstructive sleep apnea, and liver disease (MASH/NASH). These medications work by helping control blood sugar, reducing appetite, and promoting weight loss.

Because these medications can be expensive, it is important to find out whether your insurance covers them — and what your out-of-pocket cost will be — before starting treatment. This guide will help you gather the information you need.

Step 1: Know Your Diagnosis

Insurance companies require a specific medical reason (diagnosis) to approve GLP-1 medications. Check all that apply to you and bring this list when you call your insurance:

- Type 2 Diabetes (your doctor has diagnosed you with type 2 diabetes)

- Obesity (BMI of 30 or higher)

- Overweight with a related health condition (BMI of 27–29.9 PLUS one or more of the conditions below)

- Cardiovascular disease (history of heart attack, stroke, peripheral artery disease, or other heart/blood vessel disease)

- Obstructive sleep apnea (OSA) (diagnosed by a sleep study)

- MASH/NASH (fatty liver disease with inflammation or scarring, confirmed by your doctor)

- Chronic kidney disease (related to diabetes)

- High blood pressure

- High cholesterol

- Prediabetes

Your BMI: ________ (ask your doctor's office if you are unsure)

Your primary diagnosis for this medication: ________________________________

Step 2: Know Which Medication Is Being Prescribed

Different medications are approved for different conditions. Share this with your insurance company:

Step 3: Questions to Ask Your Insurance Company

Call the Member Services number on the back of your insurance card. Ask the following questions and write down the answers:

1. "Is [medication name] on my plan's formulary (list of covered drugs)?"

2. "What diagnoses qualify for coverage under my plan?"

3. "What is my copay or coinsurance for this medication?"

4. "What is my monthly out-of-pocket cost at my preferred pharmacy?"

5. "Does my plan have a specialty pharmacy requirement?"

6. "Is there a quantity limit on this medication?"

Step 4: Compare to Cash-Pay / Manufacturer Programs

**Even if your insurance covers the medication, the out-of-pocket cost through insurance may be higher than paying cash through manufacturer programs. Compare your insurance cost to these options:

Novo Nordisk (Ozempic, Wegovy, Rybelsus):

- Visit: www.novocare.com or call 1-888-693-8276

- Ask about savings cards, patient assistance programs, and cash-pay pricing

Eli Lilly (Foundayo, Mounjaro, Zepbound):

- Visit: www.lillypriceinfo.com or call 1-800-545-6962

- Ask about the Lilly Direct program, savings cards, and cash-pay pricing

Step 5: What to Bring to Your Next Appointment

- Notes from your call with your insurance company

Important Reminders

- Prior authorization is now required by nearly all insurance plans. Your doctor's office will submit this on your behalf, but having your diagnosis information ready speeds up the process.

- Do not use compounded versions of these medications, as they may contain impurities or incorrect doses.

- These are long-term medications. Stopping them typically leads to weight regain, so understanding your ongoing costs is important.