Before any coverage answer is useful you have to know which of 8 kinds of coverage is yours, because it decides which document governs your case and whether state law reaches you at all. For 4 of them it does not, and that includes the employer plans most working people are on.
By the Covered Weight editorial team · Updated Aug 3, 2026. Research and sourcing by Evan Reid.
Why this is the first question
Every other page on this site answers a question that depends on this one. A deadline, a forum, a benefit a document promises: all of them change with who pays your claims. The trap is that the answer is not printed on your insurance card, and the card often points the wrong way — an employer that pays its own claims still hires an insurance company to administer them, so the card carries that company’s name while the employer sets the terms.
Find your row below, then take its governing document and its appeal route as the ones that apply to you. If the row says state law does not reach your plan, the state pages on this site are not describing your rights, and the federal external review route is the one to read instead.
The 8 kinds of coverage
Ordered so the plans state law does not reach come first, because those readers are the ones most likely to take the wrong rule from a state page.
Employer plan that pays its own claims
State insurance law does not reach you
About two thirds of people with employer coverage are in a plan of this kind, and no state fact on this site reaches them.
The document that decides your case
your employer's plan document and Summary Plan Description
The written plan your employer adopts, summarized for members in the Summary Plan Description. Your employer pays the claims out of its own money and hires an insurance company to administer them, so the insurer's public medical policy is not the last word. The plan document is.
Ask your HR or benefits team for the full plan document and the Summary Plan Description, and read the section that lists exclusions. Weight-treatment exclusions are usually written there in one or two sentences.
Whether state law reaches you
State insurance law does not reach a self-funded employer plan. Federal law supersedes state laws that relate to an employee benefit plan, so a state coverage mandate and a state insurance department have no authority over this plan.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 3, 2026
Read the line this comes from
the provisions of this subchapter and subchapter III shall supersede any and all State laws insofar as they may now or hereafter relate to any employee benefit plan
Excerpt begins mid-sentence, after the opening clause "Except as provided in subsection (b) of this section,". Nothing inside the excerpt was altered.
Who decides
The plan sponsor sets the terms and a named fiduciary decides an appeal, even when the card carries an insurance company's name.
Where an appeal goes
the plan's own internal appeal, then a federal external review
Every employee benefit plan must run an internal appeal process, and a plan not subject to a state external review process must provide the federal external review process instead.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-29 issue date 2026-07-29 · Read Aug 3, 2026
Read the line this comes from
Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination
Excerpt ends before the sentence continues "to an appropriate named fiduciary of the plan". Nothing inside the excerpt was altered.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process
Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
Ask them this
Does the plan document exclude anti-obesity medication or bariatric surgery, and if it does not, what does prior authorization require?
Medicare, including a Part D drug plan or a Medicare Advantage plan
State insurance law does not reach you
The exclusion is written around the USE, not the molecule. The same drug can be a covered Part D drug when it is prescribed for a different condition the label supports, so the question to ask names the indication rather than the brand.
The document that decides your case
your Part D plan's formulary, sitting under the federal definition of a covered Part D drug
Two layers decide a Medicare drug question. Federal law defines what can count as a covered Part D drug at all, and your plan's formulary decides what it covers within that.
Download your plan's formulary and its coverage determination request form from the plan's member site.
Whether state law reaches you
State insurance mandates do not reach Medicare. The definition of a covered Part D drug excludes the classes a state Medicaid program may restrict, and agents used for weight loss are on that list.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 3, 2026
Read the line this comes from
Such term does not include drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1396r–8(d)(2) of this title
Excerpt ends before the sentence continues with the carve-backs for smoking cessation agents and barbiturates. The en dash inside the cross-reference is the character the source prints.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 3, 2026
Read the line this comes from
The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain.
Two consecutive paragraphs joined by a single space: the (d)(2) lead-in and item (A). No characters were changed.
Who decides
The plan makes the coverage determination and the federal definition sets the outer limit.
Where an appeal goes
a coverage determination from your plan, then a redetermination, then the federal appeal levels
A Part D plan sponsor must maintain appeal procedures for issues that involve coverage determinations.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026
Read the line this comes from
Appeal procedures that meet the requirements of this subpart for issues that involve coverage determinations.
Item (iv) reads on from the lead-in at (a)(1), "A Part D plan sponsor, for each Part D plan that it offers, must establish and maintain".
Ask them this
What indication is on the prescription, and what does the plan require for the drug and for the procedure?
TRICARE or VA health care
State insurance law does not reach you
TRICARE and VA are two different programs with two different formularies. A person eligible for both should ask each one separately.
The document that decides your case
the federal benefit regulation, plus the TRICARE or VA formulary
These are federal programs. A regulation sets the benefit and a national formulary sets which drugs are on it, so neither an employer nor a state has any part in the answer.
Check the TRICARE formulary search or the VA national formulary, and ask the pharmacy or the treatment team which criteria form applies.
Whether state law reaches you
State law does not reach a federal program. The TRICARE regulation excludes services and supplies related solely to obesity or weight reduction, with a separate written path for bariatric surgery.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
Service and supplies related “solely” to obesity or weight reduction or weight control whether surgical or nonsurgical
Excerpt ends before the sentence continues about jaw wiring and the cross-reference to paragraph (e)(15), which is the separate written path for bariatric surgery. The curly quotation marks around "solely" are the characters the source prints.
Who decides
A federal contractor or a VA facility applies the national rules; there is no state insurance regulator in this route.
Where an appeal goes
the program's own appeal process
The VA medical benefits package covers prescription drugs available under the VA national formulary system, and a non-formulary request runs through the facility's own process rather than a state one.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-38 issue date 2026-07-28 · Read Aug 3, 2026
Read the line this comes from
Prescription drugs, including over-the-counter drugs and medical and surgical supplies available under the VA national formulary system.
Item (iii) under "(1) Basic care". Nothing inside the excerpt was altered.
Ask them this
Is the drug on the formulary, which criteria apply to the procedure, and who submits each request?
No health plan right now
State insurance law does not reach you
Open enrollment and Medicaid eligibility can both change this answer, and a change of plan changes which document governs.
The document that decides your case
no plan document, so price is the whole question
With no plan there is nothing to appeal and no criteria to meet. What decides the outcome is the cash price and the channels that publish one.
Ask the pharmacy for the cash price by dose, and check whether the manufacturer publishes a direct price for people paying themselves.
Whether state law reaches you
There is no plan for state insurance law to reach.
Who decides
No payer is involved, so nothing needs approval and nothing can be denied.
Where an appeal goes
none, because there is no denial to appeal
An appeal is a challenge to a plan's decision. With no plan there is no decision to challenge.
Ask them this
What is the cash price by dose, and what is the all-in self-pay price for the procedure?
A state or local government employee health plan
State law reach not established
These plans publish their own decisions, and several have changed weight-treatment coverage in public. Read the current booklet rather than a news story about it.
The document that decides your case
the plan's benefit booklet, adopted by the state or local government that sponsors it
A government employer's plan is a governmental plan, so the federal employee-benefit statute does not apply to it. The sponsoring government sets the terms, and many of these plans pay their own claims through an administrator.
Download the benefit booklet and the pharmacy benefit documents from the plan's member site, and read the exclusions section.
Whether state law reaches you
It depends on the state. The federal employee-benefit statute does not apply to a governmental plan, so the sponsoring government's own rules govern, and whether the state insurance code applies is a question about that state.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 3, 2026
Read the line this comes from
The provisions of this subchapter shall not apply to any employee benefit plan if- (1) such plan is a governmental plan (as defined in section 1002(32) of this title);
Two consecutive paragraphs joined by a single space: the subsection (b) lead-in and item (1). No characters were changed, including the hyphen the source prints at the end of the lead-in.
Who decides
The sponsoring government sets the benefit and its administrator applies it.
Where an appeal goes
the plan's internal appeal, then whichever external review the plan has adopted
A self-insured non-federal governmental plan may use the federal external review process, so the route is a question about the plan rather than about the state.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process
Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
Ask them this
Does the benefit booklet cover anti-obesity medication and bariatric surgery, and what does each require?
Employer plan bought from an insurance company
State insurance law reaches you
The document that decides your case
the insurance policy and its certificate of coverage, plus your state's insurance rules
Your employer buys a policy and the insurance company pays the claims. The certificate of coverage is the member-facing version of that policy, and the insurer's published medical policy usually sets the approval criteria.
Ask HR or the insurer for the certificate of coverage, then look up the insurer's medical policy for the treatment by name and number.
Whether state law reaches you
State insurance law does reach this plan. Federal law expressly leaves state laws that regulate insurance in force, so a state coverage mandate and the state insurance department both apply.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 3, 2026
Read the line this comes from
nothing in this subchapter shall be construed to exempt or relieve any person from any law of any State which regulates insurance, banking, or securities.
Excerpt begins after the opening clause "Except as provided in subparagraph (B),". Nothing inside the excerpt was altered.
Who decides
The insurer pays the claims and applies its own medical policy, subject to the state's insurance rules.
Where an appeal goes
the insurer's internal appeal, then your state's external review
The plan and the insurer must run an internal claims and appeals process, and an independent external review follows it.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A group health plan and a health insurance issuer offering group or individual health insurance coverage must implement an effective internal claims and appeals process
Excerpt ends before the sentence continues ", as described in this paragraph (b).". Nothing inside the excerpt was altered.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process
Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
Ask them this
Does the certificate of coverage cover anti-obesity medication and bariatric surgery, and which medical policy numbers set the criteria?
A plan bought on the health insurance marketplace
State insurance law reaches you
The document that decides your case
your plan's evidence of coverage, on top of your state's benchmark plan
An individual marketplace plan has to match a benchmark plan your state picked, and then adds its own formulary and criteria on top. So two documents matter: your plan's evidence of coverage and the state benchmark it is measured against.
Download the evidence of coverage and the formulary from your plan's member site, then check this site's page for your state's benchmark.
Whether state law reaches you
State law reaches this plan through the benchmark. A plan sold on the marketplace must provide benefits substantially equal to the benchmark plan the state selected.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
Are substantially equal to the EHB-benchmark plan including: (i) Covered benefits;
Item (1) reads on from the lead-in at paragraph (a), "Provision of EHB means that a health plan provides benefits that". Two consecutive lines joined by a single space; no characters changed.
Who decides
The issuer applies its own formulary and criteria within the floor the state benchmark sets.
Where an appeal goes
the issuer's internal appeal, then your state's external review
The issuer must run an internal claims and appeals process, and an independent external review follows it.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A group health plan and a health insurance issuer offering group or individual health insurance coverage must implement an effective internal claims and appeals process
Excerpt ends before the sentence continues ", as described in this paragraph (b).". Nothing inside the excerpt was altered.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-45 issue date 2026-07-24 · Read Aug 3, 2026
Read the line this comes from
A plan or issuer not subject to an applicable State external review process under paragraph (c) of this section must provide an effective Federal external review process
Excerpt ends before the sentence continues "in accordance with this paragraph (d)". Nothing inside the excerpt was altered.
Ask them this
Is anti-obesity medication on the formulary and is bariatric surgery covered, and what does prior authorization require for each?
Medicaid, including a Medicaid managed care plan
State insurance law reaches you
The program's name is different in many states, and searching the name on your card finds the drug list faster than searching the word Medicaid.
The document that decides your case
your state's preferred drug list and provider manual, plus your managed care plan's formulary if you have one
Each state runs its own program and publishes its own drug list. If your card carries a health plan name as well as the state program name, that plan keeps its own formulary on top of the state list.
Look up your state program's preferred drug list, and if you are in a managed care plan, its formulary too. Both are published.
Whether state law reaches you
The state decides. Federal law lists agents used for weight loss among the drugs a state Medicaid program may exclude or restrict, which is exactly why the answer changes at the state line.
Office of the Law Revision Counsel, U.S. House of Representatives · Federal statute · prelim, current through the release point shown on the page · Read Aug 3, 2026
Read the line this comes from
The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain.
Two consecutive paragraphs joined by a single space: the (d)(2) lead-in and item (A). No characters were changed.
Who decides
A managed care plan decides in the first instance, and the state agency stands behind it.
Where an appeal goes
your plan's appeal if you are in managed care, then a state fair hearing
A managed care enrollee may request a state fair hearing after the plan upholds its decision, and the state agency must grant a hearing to anyone who believes it acted wrongly on a claim for covered benefits.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026
Read the line this comes from
An enrollee may request a State fair hearing after receiving notice under § 438.408 that the adverse benefit determination is upheld.
Second sentence of paragraph (c)(1)(i). Nothing inside the excerpt was altered.
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-42 issue date 2026-07-20 · Read Aug 3, 2026
Read the line this comes from
The State agency must grant an opportunity for a hearing to the following: (1) Any individual who requests it because he or she believes the agency has taken an action erroneously
Two consecutive paragraphs joined by a single space: the (a) lead-in and item (1). The excerpt ends before the sentence continues ", denied his or her claim for eligibility or for covered benefits or services".
Ask them this
Is the medication on the preferred drug list, is bariatric surgery covered, and what does prior authorization require for each?
Start by finding out which document governs your plan
Everything else follows from it. A state program publishes its own rules. A marketplace plan is measured against a state benchmark. An employer plan that pays claims out of the employer's own funds sets its own rules, and no state rule reaches it.
Because it decides which rules reach you. State insurance law does not reach a self-funded employer plan, so a state coverage mandate, a state deadline and a state insurance department have no authority over it. Someone on that kind of plan who follows a state appeal deadline has followed the wrong one, and an appeal deadline is not a decision you can appeal.
My card has an insurance company on it. Does that mean I am insured by them?
Not necessarily, and this is the most common way people get this wrong. An employer that pays claims out of its own money still hires an insurance company to administer them, so the card carries that company name while the employer sets the terms. The plan document decides your case, not the insurer public medical policy.
How do I find out for certain?
Ask your HR or benefits team for the full plan document and the Summary Plan Description, and read the section listing exclusions. The Summary Plan Description also says who funds the plan. For coverage that is not through an employer, the governing document named in your row below is the one to ask for.
What should I actually say when I call?
Each row below ends with the exact question to put to the plan, worded so it cannot be answered with a general yes or no. Ask whether the document excludes the treatment, and if it does not, what prior authorization requires.
