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This pattern appears most often with: HDHPs with deductibles above $3,000 Marketplace plans with high coinsurance (30-40%) on specialty tiers Plans that cover GLP-1 only with burdensome prior authorization that delays treatment 4+ weeks The decision rule: if your insurance requires you to pay more than $300/month out-of-pocket before coverage kicks in, run the math on compounded alternatives
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Coverage often requires documented BMI criteria, evidence of weight-related comorbidities (type 2 diabetes, hypertension, sleep apnea), and sometimes documentation of prior failed weight loss attempts
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