Carriers
What the carriers publish
A carrier's own coverage policies are public, numbered and dated, and they answer a narrower question than they appear to. These pages quote them, and then say plainly what they cannot tell you about your own plan.
- Cigna HealthcarePublishes three different BMI thresholds for the same drugs, and says in writing they are not clinically based.
- UnitedHealthcareSays in its own program document that weight-loss coverage is optional, and sells it to employers who choose to buy it.
- AetnaSays outright that on plans which exclude weight-loss drugs, its clinical criteria do not apply and the claim is denied on the exclusion.
The thing a carrier page gets wrong
A published clinical criterion looks like the rule that decides your case. Usually it is the second rule. The first is whether the plan you are in bought a weight-loss drug benefit at all, and that is a purchasing decision made by an employer or a plan sponsor rather than a clinical judgment made by the insurer. A carrier can publish a detailed body mass index threshold and still not pay, because the benefit the threshold sits inside was never bought.
That is why each page here leads with the benefit question and puts the clinical criteria under it, and why each one ends with a list of what its documents do not establish. If you want the rules that apply to everybody regardless of carrier, the employer plans page has the federal floor, and the commercial appeal procedure has the deadlines.
Nothing here is legal or medical advice, and no page predicts how an appeal will come out. Your plan document and the notice you received govern your case.