Modern Metabolic Health with Dr. Lindsay Ogle, MD

How To Pick Health Insurance That Covers Obesity Treatment In 2026

• Lindsay Ogle, MD • Episode 7

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The plan you choose this enrollment season can decide whether your obesity treatment moves forward or stalls out. We unpack the entire decision path so you can compare plans with confidence, avoid hidden exclusions, and secure access to the care that actually changes health.

We start by simplifying the moving parts that shape what you’ll pay: premiums, deductibles, coinsurance, copays, and the out-of-pocket maximum. Then we get tactical with FSA and HSA strategies to soften early-year costs, especially if you’re on a high-deductible plan. From there, we focus on what matters most for obesity care in 2026—how to find and interpret the exclusions list, read the drug formulary correctly, and confirm whether FDA-approved medications for obesity, Wegovy (semaglutide) and Zepbound (tirzepatide), are truly covered. We explain why Ozempic and Mounjaro listings usually apply only to type 2 diabetes, not obesity, and show you where to look for the fine print that determines approvals and denials.

You’ll also hear how plans define eligibility, including BMI thresholds and the role of weight-related conditions like hypertension, sleep apnea, dyslipidemia, prediabetes, and diabetes. We share the documentation that strengthens prior authorization—initial BMI, weight trajectory, supervised lifestyle records, and dietitian notes—and how to request written confirmation from HR, brokers, and insurers. If a plan blocks “weight loss treatment,” we cover what to ask for, how to appeal with evidence, and where to find advocacy resources and templates that improve your chances. And if coverage isn’t available this cycle, we map out practical next steps with board-certified obesity medicine care, nutrition, activity, stress, and sleep, plus smart use of FSA/HSA funds to bridge the gap.

If this guide helps you choose better, share it with someone making benefits decisions right now. Subscribe and leave a review so more people can find clear answers and take control of their metabolic health.


Links mentioned:

https://www.FSAstore.com

Https://www.obesityaction.org

https://www.obesityaction.org/wp-content/uploads/INSGUIDE713-1.pdf

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Telehealth clinic: https://missourimetabolichealth.com


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Dr. Lindsay Ogle:

Welcome to the Modern Metabolic Health Podcast with your host, Dr. Lindsay Ogle, Board Certified Family Medicine and Obesity Medicine Physician. Here we learn how we can treat and prevent modern metabolic conditions such as diabetes, PCOS, fatty liver disease, metabolic syndrome, sleep apnea, and more. We focus on optimizing lifestyle while utilizing safe and effective medical treatments. Please remember that while I am a physician, I am not your physician. Everything discussed here is provided as general medical knowledge and not direct medical advice. Please talk to your doctor about what is best for you. It's November, so in the United States, that means it is time for open enrollments for health insurance in the upcoming year of 2026. And I want to take time today to talk about what you should be looking for when choosing a health insurance plan if you have the disease of obesity and are looking for treatment in the upcoming year, or if you want to continue your current treatment plan. And right now I'm talking to all of my patients about what their insurance plans are for the upcoming year. And I wanted to go over some of these key points with everybody so you are prepared to choose the plan that is best for you. We're gonna go over the you know high-level overview of health insurance in the United States. Unfortunately, it's a very complicated system that I am still learning, even as a physician working in the healthcare space. I get confused and have to ask a lot of questions along the way. And things are evolving over time, laws are changing, coverage is changing, and so it is something that we need to constantly um keep up with. And so I'm gonna go over the highlights, the most important things again, especially for somebody who has a disease of obesity and is looking for treatment in 2026. So first we'll start with what is open enrollment. Open enrollment is a time of year where you can apply for health insurance coverage, whether you get insurance with your employer or you are purchasing your own insurance through the marketplace, or you have government insurance with Medicaid or Medicare. There are also qualifying times and experiences that you may be able to enroll throughout the year. This would be if you have a new job or move or become married or go through a divorce or have a child or retire. If these big life circumstances occur, then you can change your insurance at other periods of time. But for routine uh application for health insurance in the United States, this typically occurs in November and December. So it's a really important time to mark in the calendar and make sure you get this done for the upcoming year. So people either get their insurance through their employer or through the employer of someone in their family, or they go through the marketplace if they are self-employed or their employer does not offer insurance, or they get government insurance with Medicaid and Medicare. Medicare is for individuals who are 65 and older or who have a medical disability. Medicaid is for the um for patients with lower incomes of all ages. And before I go into what to look for when you are choosing a health insurance plan, if you have that ability to choose whether within your employer's plan or if you are looking through the marketplace, I'm going to talk about what to look for for obesity treatment, but I want to start with some key terms to be aware of and understand when you are navigating health insurance. The first term is premium. This is your monthly payments to continue your health insurance and keep your coverage active. And this varies widely depending on which plan you have. Deductible is the amount of money that you pay before your health insurance kicks in. And usually this amount is over the course of a year. And depending on what the size of your deductible is and how often you access medical care, you might reach your deductible early on in the calendar year, or you might not reach it until later on towards the end of the year. But deductible is something that is really important to look at when you are choosing a healthcare plan, because if you have a low deductible, then that means you will more quickly reach that benchmark and then insurance will start covering the rest of your medical care. If you have a high deductible plan, then usually your premiums are lower, which is why people consider it, especially if they do not utilize healthcare very often. So they have lower premiums, lower monthly payments, but they have that high deductible, so they're paying a lot out of pocket until they reach that deductible amount, and then insurance will kick in. The out-of-pocket maximum is the predetermined amount that would be the maximum that you pay in addition to your monthly premiums. People often get deductible and out-of-pocket max confused. So the big difference is the deductible is the amount that you pay up front before your health insurance kicks in, where it's paying for part of your services. Once you hit the out-of-pocket maximum, then your health insurance will cover a hundred percent of your health expenses. Another important distinction is the difference between coinsurance and co-pay. And these are two different types of plans. So some plans have a coinsurance, and this is usually split up between a percentage. So there's a percentage that you as the patient would pay, and then a percentage that the insurance will pay. And an example would be you would pay 20% of your health care costs until you reach that out-of-pocket maximum, and insurance will pay 80% of your health care costs until you reach that out-of-pocket maximum. When that out-of-pocket maximum is reached, then insurance will take over at 100%. Copays are set prices that you will pay for each visit. So typically patients have a specific copay for their primary care visits and then a copay for specialty visits. And that can vary from plan to plan, but that will be consistent throughout the year until you've reached that out-of-pocket maximum, and then insurance would no longer require you to have a copay. Some people like the copay version because you know exactly what you're gonna pay up front, and then people like that consistency. Another important consideration when choosing a health insurance plan is considering a flexible spending account or health savings account. These are often abbreviated as FSA or HSA. And these are really great tax-deferred accounts that either your employer will offer or you can sign up on your own if you are self-employed or unemployed. And these, like I said, are tax-deferred accounts. So you do not have to pay taxes on money put into these accounts, but they have to be utilized for health-related spending. The there are maximums that you can contribute each year, and that depends on if you're doing an individual account or a family account, but you can look at those limits at the year that you are applying for these accounts, and a major difference is that the FSA, the flexible spending account, the money put aside needs to be used in that calendar year. Um, usually you have until I think it's the end of January, maybe even a little bit longer the following year to spend that money, but you have to spend it that year. It does not roll over. The HSA, the health spending account, does roll over. And so typically, if you can choose between the two, the HSA is preferred because if you don't need that money for health expenses that year, you can save it for later in life and even in retirement. So um the HSA is preferred for most people, but FSA is also excellent. I also always recommend the FSA store where you can get a lot of different items like lotions and sunscreen and vitamins and other over-the-counter medical treatments or uh supplies, and I will link that below. So um, if you have extra money at the end of the year that you need to use, the FSA store can be a great place to spend that money before it goes away. These are also great options for people who are on high deductible health plans that need to pay more money up front before they reach their deductible and out-of-pocket cost. So you can utilize your FSA or HSA account towards those costs until you reach your deductible or maximum. You get an FSA or HSA card that you can use, like any credit or debit card. So it's very easy to utilize. Um, it can be a little bit intimidating to open a new account or start a new investment, but once you do it, you will realize how simple the process really is and how beneficial it can be for your finances. Okay, so now what to look for if you have obesity and are wanting to continue your treatment in 2026 or start treatment in 2026 to ensure that you have this coverage. So currently in the United States, insurance providers are not required to cover treatment for the disease of obesity. There's a lot of advocacy being done to start that to be a requirement. There is the Treat and Reduce Obesity Act, also known as TROA, that is being passed through the House and the Senate right now, and hopefully that does pass, and that would allow Medicare to cover these treatments, which will open the door to have other insurers cover and be required to cover the this really um life-saving and life-changing treatment. So anything that you can do to support this bill, please do. I will include a link for um the Obesity Action Coalition who is doing a lot to help support this bill be passed finally. But right now, like I said, insurance is not required to cover the treatment of obesity, so it is very important when you are choosing a healthcare plan to look and see if this is an included part of your health insurance. If you get your health insurance through your employer, ask your HR department, work with them to find out if it is covered, and if it's not, is this something that they can add? The Obesity Action Coalition actually has really great templates on how to advocate for including this in employers' health insurance plans, and so again, I'll link that below so you have that. Um, they also include templates for writing appeals if your prior authorizations for obesity treatment are denied, so it's a great resource to keep on hand. But what you want to look for is um oftentimes plans will have a list of exclusions, medical conditions, and treatments that are not included in their plan. So you want to take a look at that section and see if obesity treatment or sometimes they term it as weight loss treatment is listed, and if so, then that is probably not the plan for you. You can also look at the medication or drug formulary and see what medications are listed. Right now, most patients who have obesity, if they're looking for medication, are wanting to be on Zbound or Rigovi. Those are the two GLP1 medications that are FDA approved for the treatment of obesity. And so you want to look specifically for those two brand names. Oftentimes I have patients come to me who have looked at their drug formulary and see Ozimpic or Monjaro and are hopeful that this will be covered for them. But unfortunately, those brands are FDA approved only for the treatment of type 2 diabetes. And so if they do not have diabetes, then those medications will not be covered for them, even though it's on their drug formulary. So you want to look specifically for Zet-Bound and WeGovi. If you see that your plan does include the treatment of obesity and include Z-Bound and WeGovy on its formulary, then the next step is to look at their definition of obesity and if they have any particular requirements for that coverage. So, medically speaking, we typically still utilize BMI and definitely insurance plans tend to utilize BMI for the definition of obesity. And medically speaking, again, the indications for the use of anti-obesity medications and our GLP ones for the treatment of obesity are a BMI of 30 or greater or a BMI of 27 or greater with a weight-related condition like high blood pressure, high cholesterol, um, pre-diabetes, diabetes, sleep apnea, that sort of thing. I've seen plans have cutoffs of a BMI of 35 or greater. Um so this is something to look at to make sure that you qualify. And I always emphasize we are wanting to go based on your initial BMI. So especially if you've already been on a GLP1 and maybe your BMI is lower than when you started, you will go your qualification will be based on your initial BMI. And then see if they have requirements prior to coverage. Do they require a certain amount of months of medically supervised lifestyle intervention? Do they require you to try other medications first? Do they require you to work with a dietitian or a weight loss program? If you if they do and you have done those things, collect that documentation now so you can be prepared to have a successful prior authorization. And when in doubt, ask. Ask your employer, ask your HR department, ask your um marketplace broker, ask the insurance company directly. If you have any questions, if it's unclear, ask, ask, ask, and get the information that you need. Get it over the phone, ask for it in writing, ask for an email, ask for it to be mailed to you, ask what the link is to find out more information. You deserve to have these answers before you sign up for a plan. So ask, ask, ask. And ultimately, if you cannot find a plan or you do not qualify for a plan that has obesity coverage at this time, please do not give up hope. Like I said, there are a lot of people advocating for insurance requirement of the treatment of obesity, and I am very hopeful that eventually Troa, the Treat and Reduce Obesity Act, will eventually be covered and you will have coverage in the future. These things do take time, and there are other options for treatment in the meantime. We'll work with a board-certified obesity medicine physician, we'll work with a dietitian, continue healthy habits and excellent nutrition and stress management and regular physical activity and adequate sleep. All of those things will still lead you to a healthier life. So I hope this was helpful. This is a confusing world of health insurance in the United States. And if you found this to be helpful, please share with somebody else who is navigating the disease of obesity and applying for new health insurance in 2026. I hope that this will help you to improve your access to treatment or continue your access to treatment. And I look forward to talking to you next week. Take care. Thank you for listening and learning how you can improve your metabolic health in this modern world. If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review. This will help others find the podcast so they may also improve their metabolic health. I look forward to our conversation next week.