IEHP Coverage: What You Need to Know
IEHP generally provides coverage for Ozempic when prescribed for type 2 diabetes and related weight-related health issues that meet certain criteria. However, off-label use of Ozempic solely for weight loss may not be covered.
Prior Authorization
For off-label use of Ozempic for weight loss, prior authorization may be required from IEHP. This involves submitting a request with medical records to demonstrate the medical necessity of Ozempic treatment.
Cost-Saving Options
IEHP offers various cost-saving options under its pharmacy benefit, including discounts, co-pays, and financial assistance programs, for members prescribed Ozempic.
Eligibility and Benefits
Conditions Covered
Ozempic is typically covered by IEHP for:
- Obesity (BMI ≥ 30)
- Overweight (BMI 27-29.9) with a weight-related comorbidity
- BMI 25-26.9 with risk factors for heart disease
Therapeutic Benefits
Beyond weight loss, Ozempic has therapeutic benefits covered by IEHP, such as:
- Improved blood sugar control in type 2 diabetes
- Reduced risk of cardiovascular events
Off-Label Use for Weight Loss: Insurance Considerations
Insurance companies generally follow FDA guidelines and may not cover medications for off-label uses. They prioritize safety, effectiveness, and cost-effectiveness, and off-label use introduces uncertainties in these aspects.
Prior Authorization Process: Key Steps
Consult a Healthcare Provider: Determine eligibility based on weight, health status, and medical history.
Submit a Prior Authorization Request: Provide medical records, insurance information, and condition details to IEHP.
Review and Approval: IEHP may approve, deny, or request additional information.
Communication and Guidance: Collaborate with healthcare providers and IEHP for assistance throughout the process.