Navigating private insurance to get necessary weight-loss medications covered

Knowing what medications (e.g. Saxenda or Contrave) are covered by your private insurance or what you can do if they are not covered can help you and your medical team make the best decision with regards to the therapy.

Here are some helpful tips to consider (from our friends at Obesity Canada):

 If the medication prescribed by your healthcare provider is not covered by your insurance plan (fully or partially), follow these steps:

1. Consult your benefits handbook, website, or Human Resources Department to confirm whether it is covered
2. If applicable, check to see if it is covered by your partner’s health insurance. There may be opportunities for co-payments. Repeat step 1.

If the medication is not covered, don’t take “no” directly for an answer from your plan or your partner’s plan. Sometimes exceptions can be made.

1. Find out why your plan does not cover it. Was it a decision that was made by the insurance company or your employer?
   1. If a treatment is not covered, ask why to the benefits administrator, human resources department, or call the insurance company directly.
   1. If the answer is no because the treatment is not on the approved list of medications, ask the following:
      1. What is the formal exemption process?
      1. Is there a specific form I need to complete to find out if an exemption can be made?
      1. Do I need supporting documents for this exemption to be made?

Work with your health care team to establish a case and seek an exemption.

1. Establish a case for why you may benefit from this treatment. Ask your health care provider to put it in writing and to include details about why they are prescribing the specific treatment in question (as opposed to an alternative)
2. Explain to them in writing how your condition affects your quality of life, workplace experience, relationships, and other impacts. Meet with them in person to ensure they understand your and your health provider’s point of view.
3. Provide this information to your employer and ask that they direct their benefits provider to cover the cost of the medication

Note: Some health care providers will charge a fee to complete or sign the forms, so make sure to ask beforehand. Pharmacists may also be able to provide support for why you may benefit from the medication.

Knowing what medications (e.g. Saxenda or Contrave) are covered by your private insurance or what you can do if they are not covered can help you and your medical team make the best decision with regards to the therapy.

Here are some helpful tips to consider (from our friends at Obesity Canada):

 If the medication prescribed by your healthcare provider is not covered by your insurance plan (fully or partially), follow these steps:

1. Consult your benefits handbook, website, or Human Resources Department to confirm whether it is covered
2. If applicable, check to see if it is covered by your partner’s health insurance. There may be opportunities for co-payments. Repeat step 1.

If the medication is not covered, don’t take “no” directly for an answer from your plan or your partner’s plan. Sometimes exceptions can be made.

1. Find out why your plan does not cover it. Was it a decision that was made by the insurance company or your employer?
   1. If a treatment is not covered, ask why to the benefits administrator, human resources department, or call the insurance company directly.
   1. If the answer is no because the treatment is not on the approved list of medications, ask the following:
      1. What is the formal exemption process?
      1. Is there a specific form I need to complete to find out if an exemption can be made?
      1. Do I need supporting documents for this exemption to be made?

Work with your health care team to establish a case and seek an exemption.

1. Establish a case for why you may benefit from this treatment. Ask your health care provider to put it in writing and to include details about why they are prescribing the specific treatment in question (as opposed to an alternative)
2. Explain to them in writing how your condition affects your quality of life, workplace experience, relationships, and other impacts. Meet with them in person to ensure they understand your and your health provider’s point of view.
3. Provide this information to your employer and ask that they direct their benefits provider to cover the cost of the medication

Note: Some health care providers will charge a fee to complete or sign the forms, so make sure to ask beforehand. Pharmacists may also be able to provide support for why you may benefit from the medication.