Glucagon-like peptide-1 (GLP-1) medications, such as tirzepatide (sold as Zepbound for weight loss and Mounjaro (for diabetics) and semaglutide (sold as Wegovy for weight loss and Ozempic for diabetics), have gained significant popularity due to their ability to help individuals with obesity achieve meaningful weight loss and better control of blood sugars. Despite their use doubling this past decade, many patients find these treatments financially challenging.
While GLP-1s are covered by some insurance plans, eligibility depends on many factors. Without insurance, these medications can cost up to $1,000 and $1,500 per month, totaling over $12,000 annually for lifelong use. For those not eligible for coverage, alternative paths to lasting weight loss may be more financially accessible.
Factors Influencing GLP-1 Coverage
The following factors influence GLP-1 coverage:
1. Prescribed Use
Insurance coverage for GLP-1 medications depends on their prescribed use. Coverage is more likely for FDA-approved uses, such as managing type 2 diabetes. For weight loss alone, coverage is less frequent.
This disparity exists because insurers assess the financial impact on all plan members’ premiums. Because Ozempic and other weight loss medications are expensive, broad coverage for weight loss could significantly elevate costs for all plan members.
For example, if Medicare were to cover weight-loss medications such as GLP-1s, the projected cost would be around $35 billion from 2026 to 2034. While these drugs may improve health and minimize some future expenses, these savings generally do not outweigh the immediate cost.
Additionally, insurers view diabetes treatment as medically necessary. Weight management is often seen as elective, despite research highlighting the health impacts of obesity.
2. Plan Specifics
Coverage for weight loss medications varies by plan, with some insurers adding new rules or limiting options. For example, Medicaid coverage for obesity drugs differs significantly by state. Employer-sponsored plans, which are the most popular in the U.S. and cover approximately 154 million people, can choose whether or not to offer GLP-1s.
According to KFF’s Employer Health Benefits Survey, half of employers decline coverage for weight loss drugs due to high costs. For those who do GLP-1s for weight loss, specific requirements often limit employee access but generate cost savings.
3. Prior Authorization and Step Therapy
Even when GLP-1 medications are covered for weight loss, patients often face additional requirements. A common step is prior authorization (PA), which is a mandatory review by insurance companies before a prescription is filled.
For PA, insurers typically mandate a body mass index (BMI) of
a BMI of 30, or a BMI of 27 with weight-related comorbidities (hypertension, high cholesterol, sleep apnea). Some insurers recognize that Asians may develop obesity-related conditions at lower BMI levels and may permit these medications for them at lower BMI thresholds, though most standard commercial insurers stick to the 27–30+ range
Another requirement is step therapy, where patients are required first to try less expensive weight-loss medications or diet and lifestyle changes for a period of 3-6 months before they consider them eligible.
Step therapy is a “fail first” strategy that helps insurers manage costs. It requires demonstrating that initial, lower-cost options are ineffective before GLP-1s are approved. This may involve behavior support, dietitians or other medications.
As part of the PA process, a physician must submit the patient’s BMI, medical records, health history and evidence of lifestyle changes to the insurer. The insurer will then either approve or deny coverage.
Diabetics (i.e., those with a hemoglobin A1c (Hb A1c) of 6.5 or greater or fasting plasma sugar of 126mg/dL or greater typically get approved easier.
What Are Patients’ Options if GLP-1 Coverage Is Denied?
If GLP-1 coverage is denied, patients have the right to appeal this decision. The appeal process involves the following steps:
- Review the denial letter for the reasons for the denial.
- Contact the insurer for clarification.
- Gather all the requested information.
- Collaborate with the prescriber to write an appeal letter.
- Submit the appeal before the deadline.
Several appeal attempts may be necessary, yet approval is never guaranteed.
An alternative is to explore patient assistance programs (PAPs). These third-party or manufacturer-sponsored services help low-income individuals access GLP-1s at reduced or no cost. Manufacturer coupons and savings cards are also viable options.
For those ineligible for PAPs or discounted medication, paying for these medications out-of-pocket is the only other recourse.
Evaluating the Predictability and Permanence of GLP-1s
Although GLP-1s are intended for long-term use, the financial commitment is not feasible for all Americans, particularly considering the monthly cost can reach around $1,500 without insurance.
Even with initial PA, insurers monitor adherence and expect specific weight-loss outcomes
— typically between 5% and 10% of patients’ weight — for reapproval and sustained coverage. Approval criteria are subject to change and are anticipated to become more restrictive. Consequently, individuals may face denial of reapproval, leading to loss of coverage.
Cost is one of the primary reasons for discontinued use of Wegovy or Ozempic, Zepbound or Mounjaro and similar medications. Although it is possible to maintain weight loss without GLP-1s, the body no longer has the drug to curb appetite. Consequently, patients’ hunger signals can return, making weight regain common.
As these drugs help regulate blood sugar, stopping them can also cause one’s levels to increase. Those with diabetes have reported worse blood sugar spikes and higher levels than before they started taking GLP-1s.
Is There a More Permanent Solution for Weight Loss?
Also known as bariatric surgery, weight loss surgery provides a permanent solution for achieving substantial and lasting weight loss. These operations alter the digestive system, which in-turn seems to work by restoring better gut-brain signaling facilitating long-term weight management with outcomes three to five times greater than those achieved with lifestyle modifications and medications alone.
A key benefit of surgery extends beyond the improved confidence that weight loss offers, impacting various obesity-related health issues. For example, many patients experience remission or remarkable improvement in Type 2 diabetes particularly after the Duodenal Switch which is associated with > 90% remission rate for diabetes [insert link to our website/ other source]. Surgery also induces hormonal changes in the gut that medications cannot replicate, promoting enhanced metabolic stability and insulin sensitivity.
Bariatric surgery can also resolve/ improve sleep apnea. A 2025 study demonstrated a 52.6% one-year cure rate for the condition following surgery, with only 12.3% of patients still requiring Continuous Positive Airway Pressure machines for moderate to severe sleep apnea.
With dedicated support and follow-up care, weight loss surgery reliably delivers lasting results, profoundly enhancing one’s quality of life. Consequently, it stands as the most effective intervention for treating obesity.
Navigating the Financials of Weight Loss Surgery
Unlike GLP-1s, which need to be taken regularly and involve recurring and unpredictable monthly costs, weight loss surgery is often a straightforward, one-time investment that is typically covered by most insurance plans for patients meeting their criteria (typically for those with a BMI >35). It brings about lasting weight loss and the resolution/improvement of chronic diseases associated with obesity such as diabetes, hypertriglyceridemia, hypercholesterolemia, hypertension, sleep apnea and polycystic ovarian syndrome (PCOS) a common cause for infertility associated with obesity,
Many polices cover options such as the Sleeve Gastrectomy, Duodenal Switch, and the Roux-en-Y gastric bypass and some have started to cover the Single Anastomosis Duodenal-Ileal Bypass (SADI) – a variant of the Duodenal Switch While insurance coverage for bariatric surgeries has expanded, individual coverage still varies depending on a patient’s specific policy. Verifying one’s level of coverage and the services included is vital.
For those with coverage, insurers often require patients to meet specific criteria before approving the surgery:
- A BMI of 40 or above
- A BMI between 35 and 39.9 with weight-related comorbidities
- A BMI between 30 and 34.9 with Type 2 diabetes
- Completion of a mental and physical health assessment
- Participation in a clinician-supervised diet program of between one and six months
For uninsured patients who are good candidates for weight loss surgery, surgical centers frequently provide discounted self-pay and financing options, making these life-changing interventions more accessible.
Your Next Step With the Center for Weight Loss Surgery
When GLP-1 medication coverage is not an option, bariatric surgery stands as an effective alternative. It facilitates long-term meaningful weight loss, that is typically 3-5x what can be achieved with medications and leads to significant improvement or remission of various obesity-related conditions.
Guided by board-certified bariatric surgeon Dr. Myur Srikanth, the expert team at the Center for Weight Loss Surgery is ready to support you in your weight loss journey. We deliver personalized care, comprehensive education and ongoing guidance from your initial consultation through long-term follow-up. With diverse surgical options tailored to your individual needs, our team will help you select the ideal plan for you.
For those who are not covered or do not have insurance, we provide discounted self-pay options and financing solutions. Take the next step to a healthier life and schedule a consultation with our experienced clinicians today.
