How To Pick Health Insurance That Covers Obesity Treatment In 2026

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

👩🏼‍⚕️ Live in Missouri? What to be my patient?
Telehealth clinic: https://missourimetabolichealth.com

✨Freebies✨
Anti-Obesity Medication Options
How To Prevent Diabetes
Healthy Habits Workbook
Preventative Health Checklist

🤗 Socials:
Instagram: https://www.instagram.com/dr.lindsayogle/
TikTok: https://www.tiktok.com/@dr..lindsay.ogle?_t=8prC4VUQZ5i&_r=1

Episode Transcript

Dr. Lindsay Ogle (00:00):
Welcome to the Modern Metabolic Health Podcast
with your host, Dr.
Lindsay Ogle, Board CertifiedFamily Medicine and Obesity
Medicine Physician.
Here we learn how we can treatand prevent modern metabolic
conditions such as diabetes,PCOS, fatty liver disease,
metabolic syndrome, sleep apnea,and more.

(00:21):
We focus on optimizinglifestyle while utilizing safe
and effective medicaltreatments.
Please remember that while I ama physician, I am not your
physician.
Everything discussed here isprovided as general medical
knowledge and not direct medicaladvice.
Please talk to your doctorabout what is best for you.
It's November, so in the UnitedStates, that means it is time

(00:48):
for open enrollments for healthinsurance in the upcoming year
of 2026.
And I want to take time todayto talk about what you should be
looking for when choosing ahealth insurance plan if you
have the disease of obesity andare looking for treatment in the
upcoming year, or if you wantto continue your current

(01:12):
treatment plan.
And right now I'm talking toall of my patients about what
their insurance plans are forthe upcoming year.
And I wanted to go over some ofthese key points with everybody
so you are prepared to choosethe plan that is best for you.
We're gonna go over the youknow high-level overview of

(01:35):
health insurance in the UnitedStates.
Unfortunately, it's a verycomplicated system that I am
still learning, even as aphysician working in the
healthcare space.
I get confused and have to aska lot of questions along the
way.
And things are evolving overtime, laws are changing,
coverage is changing, and so itis something that we need to

(01:57):
constantly um keep up with.
And so I'm gonna go over thehighlights, the most important
things again, especially forsomebody who has a disease of
obesity and is looking fortreatment in 2026.
So first we'll start with whatis open enrollment.
Open enrollment is a time ofyear where you can apply for
health insurance coverage,whether you get insurance with

(02:21):
your employer or you arepurchasing your own insurance
through the marketplace, or youhave government insurance with
Medicaid or Medicare.
There are also qualifying timesand experiences that you may be
able to enroll throughout theyear.
This would be if you have a newjob or move or become married

(02:45):
or go through a divorce or havea child or retire.
If these big life circumstancesoccur, then you can change your
insurance at other periods oftime.
But for routine uh applicationfor health insurance in the
United States, this typicallyoccurs in November and December.
So it's a really important timeto mark in the calendar and

(03:08):
make sure you get this done forthe upcoming year.
So people either get theirinsurance through their employer
or through the employer ofsomeone in their family, or they
go through the marketplace ifthey are self-employed or their
employer does not offerinsurance, or they get
government insurance withMedicaid and Medicare.

(03:30):
Medicare is for individuals whoare 65 and older or who have a
medical disability.
Medicaid is for the um forpatients with lower incomes of
all ages.
And before I go into what tolook for when you are choosing a

(03:51):
health insurance plan, if youhave that ability to choose
whether within your employer'splan or if you are looking
through the marketplace, I'mgoing to talk about what to look
for for obesity treatment, butI want to start with some key
terms to be aware of andunderstand when you are
navigating health insurance.

(04:11):
The first term is premium.
This is your monthly paymentsto continue your health
insurance and keep your coverageactive.
And this varies widelydepending on which plan you
have.
Deductible is the amount ofmoney that you pay before your
health insurance kicks in.

(04:32):
And usually this amount is overthe course of a year.
And depending on what the sizeof 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 theyear.
But deductible is somethingthat is really important to look

(04:52):
at when you are choosing ahealthcare plan, because if you
have a low deductible, then thatmeans you will more quickly
reach that benchmark and theninsurance will start covering
the rest of your medical care.
If you have a high deductibleplan, then usually your premiums

(05:13):
are lower, which is why peopleconsider it, especially if they
do not utilize healthcare veryoften.
So they have lower premiums,lower monthly payments, but they
have that high deductible, sothey're paying a lot out of
pocket until they reach thatdeductible amount, and then
insurance will kick in.
The out-of-pocket maximum isthe predetermined amount that

(05:36):
would be the maximum that youpay in addition to your monthly
premiums.
People often get deductible andout-of-pocket max confused.
So the big difference is thedeductible is the amount that
you pay up front before yourhealth insurance kicks in, where
it's paying for part of yourservices.
Once you hit the out-of-pocketmaximum, then your health

(06:00):
insurance will cover a hundredpercent of your health expenses.
Another important distinctionis the difference between
coinsurance and co-pay.
And these are two differenttypes of plans.
So some plans have acoinsurance, and this is usually
split up between a percentage.
So there's a percentage thatyou as the patient would pay,

(06:23):
and then a percentage that theinsurance will pay.
And an example would be youwould pay 20% of your health
care costs until you reach thatout-of-pocket maximum, and
insurance will pay 80% of yourhealth care costs until you
reach that out-of-pocketmaximum.
When that out-of-pocket maximumis reached, then insurance will

(06:46):
take over at 100%.
Copays are set prices that youwill pay for each visit.
So typically patients have aspecific copay for their primary
care visits and then a copayfor specialty visits.
And that can vary from plan toplan, but that will be

(07:06):
consistent throughout the yearuntil you've reached that
out-of-pocket maximum, and theninsurance would no longer
require you to have a copay.
Some people like the copayversion because you know exactly
what you're gonna pay up front,and then people like that
consistency.
Another important considerationwhen choosing a health
insurance plan is considering aflexible spending account or

(07:32):
health savings account.
These are often abbreviated asFSA or HSA.
And these are really greattax-deferred accounts that
either your employer will offeror you can sign up on your own
if you are self-employed orunemployed.
And these, like I said, aretax-deferred accounts.

(07:55):
So you do not have to pay taxeson money put into these
accounts, but they have to beutilized for health-related
spending.
The there are maximums that youcan contribute each year, and
that depends on if you're doingan individual account or a
family account, but you can lookat those limits at the year

(08:18):
that you are applying for theseaccounts, and a major difference
is that the FSA, the flexiblespending account, the money put
aside needs to be used in thatcalendar year.
Um, usually you have until Ithink it's the end of January,
maybe even a little bit longerthe following year to spend that

(08:38):
money, but you have to spend itthat year.
It does not roll over.
The HSA, the health spendingaccount, does roll over.
And so typically, if you canchoose between the two, the HSA
is preferred because if youdon't need that money for health
expenses that year, you cansave it for later in life and

(08:59):
even in retirement.
So um the HSA is preferred formost people, but FSA is also
excellent.
I also always recommend the FSAstore where you can get a lot
of different items like lotionsand sunscreen and vitamins and
other over-the-counter medicaltreatments or uh supplies, and I

(09:24):
will link that below.
So um, if you have extra moneyat the end of the year that you
need to use, the FSA store canbe a great place to spend that
money before it goes away.
These are also great optionsfor people who are on high
deductible health plans thatneed to pay more money up front
before they reach theirdeductible and out-of-pocket

(09:47):
cost.
So you can utilize your FSA orHSA account towards those costs
until you reach your deductibleor maximum.
You get an FSA or HSA card thatyou can use, like any credit or
debit card.
So it's very easy to utilize.
Um, it can be a little bitintimidating to open a new

(10:08):
account or start a newinvestment, but once you do it,
you will realize how simple theprocess really is and how
beneficial it can be for yourfinances.
Okay, so now what to look forif you have obesity and are
wanting to continue yourtreatment in 2026 or start

(10:29):
treatment in 2026 to ensure thatyou have this coverage.
So currently in the UnitedStates, insurance providers are
not required to cover treatmentfor the disease of obesity.
There's a lot of advocacy beingdone to start that to be a
requirement.
There is the Treat and ReduceObesity Act, also known as TROA,

(10:52):
that is being passed throughthe House and the Senate right
now, and hopefully that doespass, and that would allow
Medicare to cover thesetreatments, which will open the
door to have other insurerscover and be required to cover
the this really um life-savingand life-changing treatment.

(11:16):
So anything that you can do tosupport this bill, please do.
I will include a link for umthe Obesity Action Coalition who
is doing a lot to help supportthis 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

(11:36):
are choosing a healthcare planto look and see if this is an
included part of your healthinsurance.
If you get your healthinsurance through your employer,
ask your HR department, workwith them to find out if it is
covered, and if it's not, isthis something that they can
add?
The Obesity Action Coalitionactually has really great

(11:57):
templates on how to advocate forincluding this in employers'
health insurance plans, and soagain, I'll link that below so
you have that.
Um, they also include templatesfor writing appeals if your
prior authorizations for obesitytreatment are denied, so it's a
great resource to keep on hand.

(12:19):
But what you want to look foris um oftentimes plans will have
a list of exclusions, medicalconditions, and treatments that
are not included in their plan.
So you want to take a look atthat section and see if obesity
treatment or sometimes they termit as weight loss treatment is

(12:40):
listed, and if so, then that isprobably not the plan for you.
You can also look at themedication or drug formulary and
see what medications arelisted.
Right now, most patients whohave obesity, if they're looking
for medication, are wanting tobe on Zbound or Rigovi.

(13:03):
Those are the two GLP1medications that are FDA
approved for the treatment ofobesity.
And so you want to lookspecifically for those two brand
names.
Oftentimes I have patients cometo me who have looked at their
drug formulary and see Ozimpicor Monjaro and are hopeful that
this will be covered for them.
But unfortunately, those brandsare FDA approved only for the

(13:27):
treatment of type 2 diabetes.
And so if they do not havediabetes, then those medications
will not be covered for them,even though it's on their drug
formulary.
So you want to lookspecifically for Zet-Bound and
WeGovi.
If you see that your plan doesinclude the treatment of obesity
and include Z-Bound and WeGovyon its formulary, then the next

(13:51):
step is to look at theirdefinition of obesity and if
they have any particularrequirements for that coverage.
So, medically speaking, wetypically still utilize BMI and
definitely insurance plans tendto utilize BMI for the

(14:11):
definition of obesity.
And medically speaking, again,the indications for the use of
anti-obesity medications and ourGLP ones for the treatment of
obesity are a BMI of 30 orgreater or a BMI of 27 or
greater with a weight-relatedcondition like high blood

(14:31):
pressure, high cholesterol, um,pre-diabetes, diabetes, sleep
apnea, that sort of thing.
I've seen plans have cutoffs ofa BMI of 35 or greater.
Um so this is something to lookat to make sure that you
qualify.
And I always emphasize we arewanting to go based on your
initial BMI.

(14:52):
So especially if you've alreadybeen on a GLP1 and maybe your
BMI is lower than when youstarted, you will go your
qualification will be based onyour initial BMI.
And then see if they haverequirements prior to coverage.
Do they require a certainamount of months of medically
supervised lifestyleintervention?

(15:14):
Do they require you to tryother medications first?
Do they require you to workwith a dietitian or a weight
loss program?
If you if they do and you havedone those things, collect that
documentation now so you can beprepared to have a successful
prior authorization.
And when in doubt, ask.

(15:35):
Ask your employer, ask your HRdepartment, ask your um
marketplace broker, ask theinsurance company directly.
If you have any questions, ifit's unclear, ask, ask, ask, and
get the information that youneed.
Get it over the phone, ask forit in writing, ask for an email,

(15:59):
ask for it to be mailed to you,ask what the link is to find
out more information.
You deserve to have theseanswers before you sign up for a
plan.
So ask, ask, ask.
And ultimately, if you cannotfind a plan or you do not
qualify for a plan that hasobesity coverage at this time,

(16:21):
please do not give up hope.
Like I said, there are a lot ofpeople advocating for insurance
requirement of the treatment ofobesity, and I am very hopeful
that eventually Troa, the Treatand Reduce Obesity Act, will
eventually be covered and youwill have coverage in the
future.
These things do take time, andthere are other options for

(16:45):
treatment in the meantime.
We'll work with aboard-certified obesity medicine
physician, we'll work with adietitian, continue healthy
habits and excellent nutritionand stress management and
regular physical activity andadequate sleep.
All of those things will stilllead you to a healthier life.
So I hope this was helpful.
This is a confusing world ofhealth insurance in the United

(17:09):
States.
And if you found this to behelpful, please share with
somebody else who is navigatingthe disease of obesity and
applying for new healthinsurance in 2026.
I hope that this will help youto improve your access to
treatment or continue youraccess to treatment.

(17:30):
And I look forward to talkingto you next week.
Take care.
Thank you for listening andlearning how you can improve
your metabolic health in thismodern world.
If you found this informationhelpful, please share with a
friend, family member, orcolleague.

(17:50):
We need to do all we can tocombat the dangerous
misinformation that is outthere.
Please subscribe and write areview.
This will help others find thepodcast so they may also improve
their metabolic health.
I look forward to ourconversation next week.