What should be included in a patient's history, along with obesity, for insurance to cover the cost of weight loss medication such as orlistat (generic), phentermine-topiramate (generic), or liraglutide (generic)?

Insurance Coverage Requirements for Weight Loss Medications

For insurance to cover weight loss medications such as orlistat, phentermine-topiramate, or liraglutide, the patient's history must document a BMI ≥30 kg/m² or ≥27 kg/m² with at least one weight-related comorbidity such as type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea. 1

Required Documentation for Insurance Coverage

• BMI calculation: Must be clearly documented in the medical record showing either ≥30 kg/m² or ≥27 kg/m² with comorbidities 2, 1

• Weight-related comorbidities: Documentation of at least one of the following:

  • Type 2 diabetes or prediabetes 2
  • Hypertension 1
  • Dyslipidemia 1
  • Obstructive sleep apnea 1
  • Other obesity-related complications that impact quality of life 1

• Failed lifestyle interventions: Evidence of previous weight loss attempts through:

  • Specific diet plans and nutritional counseling 1
  • Structured exercise regimens 1
  • Behavioral therapy attempts 1
  • Documentation of inadequate response to these interventions 2, 1

Medication-Specific Requirements

Orlistat

• Generally more readily covered as it's available over-the-counter at lower doses (60mg) and has been FDA-approved since 1999 2, 1
• Documentation of tolerance to gastrointestinal side effects may be required 2
• Average wholesale price: $41-$82 for a 30-day supply 2

Phentermine-Topiramate (Qsymia)

• Requires documentation of 3% weight loss at 12 weeks on the 7.5/46mg dose to continue coverage 2, 1
• Contraindications must be addressed (cardiovascular disease, glaucoma, hyperthyroidism) 2
• Average wholesale price: $223 for a 30-day supply 2

Liraglutide (Saxenda)

• Often requires evidence of failed attempts with other medications 1
• Documentation of regular monitoring for potential side effects 2
• Average wholesale price: $1,619 for a 30-day supply 2

Ongoing Coverage Requirements

• Most insurers require evidence of approximately 5% weight loss within 12 weeks of starting medication to continue coverage 2, 1
• Regular follow-up visits must be documented:
  • Monthly visits for the first 3 months 1
  • Every 3 months thereafter 1
• Continued documentation of the medication's impact on comorbidities and quality of life 1

Common Pitfalls and How to Avoid Them

• Incomplete documentation: Ensure all medical records clearly document obesity diagnosis, BMI calculations, and specific comorbidities 1

• Inadequate lifestyle intervention documentation: Provide specific details about diet plans, exercise regimens, and behavioral therapy attempts with dates and outcomes 1

• Failure to meet progress requirements: Understand that continued coverage requires documented weight loss progress (typically 5% of body weight within 3-4 months) 2, 1

• Not addressing medication contraindications: Document screening for contraindications to specific medications, as these may affect coverage decisions 2, 1

• Missing medication-specific requirements: Each medication has unique coverage criteria that must be addressed in documentation 2, 1

Special Considerations

• Medicare explicitly excludes coverage for obesity medications unless they are being used for other approved indications 3

• Medicaid coverage varies significantly by state, with only seven state programs offering coverage for weight loss medications 3

• For newer GLP-1 agonists, more extensive documentation and prior authorization are typically required due to their higher cost 1, 4