Does Humana Cover Weight Loss Treatment in West Virginia? A 2026 Guide

Last updated: July 16, 2026

Key update — Medicare GLP-1 Bridge (July 1, 2026): Starting July 1, 2026, eligible Humana Medicare Advantage members in West Virginia may access Wegovy (semaglutide), Zepbound (tirzepatide), and Foundayo at $50/month through a new CMS program — outside the standard HPS Part D formulary. This program is available to qualifying Medicare Advantage Prescription Drug (MAPD) plan members. Contact CMS at 1-800-633-4227 or your Humana plan for eligibility details.

Important: Humana operates as Medicare Advantage only in West Virginia — Humana no longer offers commercial (employer or individual) health plans in this state. This guide covers Humana Medicare Advantage plans only.

→ Check if Klarity’s weight loss providers may accept your Humana MA plan

Last updated: July 16, 2026

Does Humana Cover Weight Loss Treatment in West Virginia?

Weight loss treatment coverage under Humana Medicare Advantage plans in West Virginia depends on your specific plan, your body mass index (BMI), documented comorbidities, and whether the medication or service is included in your plan’s benefits. Humana’s Medicare Advantage plans are administered through Humana Pharmacy Solutions (HPS) for prescription benefits and are governed by federal CMS regulations — not West Virginia state insurance law.

As of July 1, 2026, a landmark Medicare GLP-1 Bridge program gives eligible MAPD members access to Wegovy, Zepbound, and Foundayo at $50/month through CMS — a significant change for West Virginia Medicare Advantage members seeking GLP-1 coverage.

This guide covers the HPS Part D formulary for weight loss medications, the Medicare GLP-1 Bridge program, prior authorization requirements, EPCS prescribing rules, parity rights, and how to verify your benefits.

Medicare GLP-1 Bridge Program — What West Virginia Humana Members Need to Know

The Medicare GLP-1 Bridge is a CMS-administered program that launched July 1, 2026, providing Medicare Advantage Prescription Drug (MAPD) plan members access to FDA-approved GLP-1 weight loss medications at a reduced cost:

• Covered medications: Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide), Foundayo
• Member cost: $50/month for eligible MAPD plan members
• Program basis: This is a CMS program — it operates outside the standard HPS Part D formulary. It is not subject to the same formulary tier or PA restrictions as standard Part D coverage
• Eligibility: Medicare Advantage members enrolled in a plan with Part D coverage; BMI and clinical criteria may apply
• How to access: Contact Humana at 1-800-448-6262 or CMS at 1-800-633-4227 to confirm your plan’s participation and eligibility requirements

Important distinction: Mounjaro (tirzepatide) and Ozempic/Rybelsus (semaglutide) are indicated for type 2 diabetes management — they are separate from Zepbound and Wegovy, which are the FDA-approved weight loss formulations. The GLP-1 Bridge covers the weight loss formulations specifically.

HPS Part D Weight Loss Formulary (Standard Coverage)

Outside the Medicare GLP-1 Bridge program, standard Part D coverage for weight loss medications has historically been limited. The table below reflects typical HPS formulary tier placement for Part D plans — individual plan formularies vary and members should verify with their specific plan.

Formulary tiers and PA requirements vary by specific Humana MA plan. Always verify with HPS (1-800-379-0092) or your plan’s Evidence of Coverage document.

EPCS Requirements for Weight Loss Medications in West Virginia

West Virginia requires electronic prescribing of controlled substances (EPCS) under W. Va. Code § 60A-4-403a, which applies to all controlled substances — not just Schedule II. This is broader than most states, which typically limit EPCS mandates to Schedule II.

EPCS applicability by medication:

• Phentermine (Schedule IV): EPCS required under § 60A-4-403a. Prescribers must use a DEA-compliant EPCS-enabled electronic health record system. Paper prescriptions for phentermine are generally not permitted in WV for outpatient prescribing.
• Qsymia (phentermine/topiramate ER, Schedule IV): EPCS required under § 60A-4-403a. Additionally, Qsymia is subject to an FDA REMS program requiring prescriber certification, pharmacy enrollment, and patient enrollment (iPledge-equivalent). Both EPCS and REMS compliance are required.
• GLP-1 agonists (Wegovy, Zepbound, Saxenda, Foundayo): Non-scheduled medications — EPCS entirely inapplicable. No controlled substance prescribing restrictions apply.
• Contrave (naltrexone/bupropion): Non-scheduled — EPCS inapplicable.
• Orlistat: Non-scheduled — EPCS inapplicable.

Klarity Health providers operate EPCS-compliant prescribing systems and are able to prescribe Schedule IV medications including phentermine where clinically appropriate and legally permissible.

Prior Authorization for Weight Loss Medications Under Humana MA in West Virginia

Most weight loss medications under Humana Medicare Advantage require prior authorization. Typical PA criteria may include:

• BMI ≥30 kg/m², or BMI ≥27 kg/m² with at least one weight-related comorbidity (type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea)
• Documentation of previous lifestyle modification attempts (diet and exercise program)
• Prescriber attestation of clinical appropriateness
• Absence of contraindications (e.g., pregnancy, certain cardiac conditions for phentermine)

How to submit PA requests for Humana MA in West Virginia:

• Electronic: Availity (availity.com) — preferred channel for PA submissions
• Provider portal: humana.com/providers
• Phone: HPS 1-800-379-0092 (pharmacy); Humana 1-800-448-6262 (member services)

WV SB 267 (2024) — note on applicability: West Virginia SB 267 requires electronic PA submission via Availity for state-regulated commercial insurers. However, Humana Medicare Advantage plans are federally regulated under 42 U.S.C. § 1395w-26(b)(3) — federal preemption applies, and SB 267 does not govern Humana MA. Availity remains a valid and preferred submission channel, but the legal basis is federal MA requirements rather than WV SB 267.

CMS Part D PA decision timelines (Medicare Advantage):

• Standard PA decision: within 72 hours (for Part D formulary exceptions) or 14 days for coverage determinations
• Expedited decision: within 24 hours when a standard timeline would seriously jeopardize health
• Redetermination appeal: 7-day standard / 72-hour expedited
• Independent Review Entity (IRE): 60 days standard / 72 hours expedited

Parity Rights and Weight Loss Coverage Under Humana MA in West Virginia

West Virginia’s mental health parity law (W. Va. Code § 33-25-8r et seq.) covers mental health and substance use disorder benefits. It does not govern weight loss treatment coverage — weight loss is not classified as a mental health or substance use disorder condition under WV parity statute.

Weight loss treatment coverage for Humana Medicare Advantage members in West Virginia is governed by:

• CMS 42 CFR Part 422 — federal Medicare Advantage regulations
• ACA Essential Health Benefits (EHB) framework
• Your plan’s Evidence of Coverage (EOC) document, which defines covered services and exclusions

Under Medicare Advantage, CMS enforces federal parity and benefit requirements. Members may file complaints or grievances with CMS at 1-800-633-4227 or at medicare.gov/claims-appeals.

For Medicare Advantage, WV Insurance Commissioner oversight is limited. The primary regulatory authority for benefit disputes is CMS, not the WV Insurance Commissioner. If you need regulatory assistance, contact CMS directly rather than (or in addition to) the WV Insurance Commissioner at 1-888-879-9842.

Humana MA Weight Loss Coverage — What Is Typically Covered

Beyond prescription medications, Humana Medicare Advantage plans in West Virginia may cover additional weight management services:

• Obesity counseling: Medicare covers intensive behavioral therapy for obesity (IBT) — up to 22 visits in year 1 and 12 visits in year 2 — with primary care physicians for beneficiaries with BMI ≥30
• Nutritional counseling: Covered for certain diagnoses (diabetes, kidney disease) under Medicare; may extend to obesity counseling through MA supplemental benefits
• Bariatric surgery: Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding may be covered with PA for eligible members (BMI ≥40, or BMI ≥35 with comorbidities, with documented prior weight loss attempts)
• Telehealth weight management: Humana MA telehealth benefits vary by plan — verify with your specific plan whether telehealth-delivered weight management services are covered
• Supplemental benefits: Some Humana MA plans offer fitness benefits (SilverSneakers) and over-the-counter (OTC) allowances that may support weight management goals

Klarity Health and Humana MA Weight Loss Coverage in West Virginia

Klarity Health has 2,000+ licensed providers offering telehealth weight loss treatment, including GLP-1 medication management, across West Virginia. Klarity providers work with Medicare Advantage patients and can assist with:

• Medical evaluation for weight loss medication eligibility
• Prior authorization documentation and support
• EPCS-compliant prescribing for Schedule IV medications (phentermine, Qsymia) where appropriate
• Guidance on the Medicare GLP-1 Bridge program eligibility
• Ongoing weight management and monitoring via telehealth

See if Klarity’s weight loss providers may be covered under your Humana MA plan →

How to Verify Your Humana MA Weight Loss Benefits in West Virginia

1. Review your Evidence of Coverage (EOC): Log in to humana.com and download your plan’s EOC document — it lists covered services, formulary tiers, and PA requirements
2. Check the HPS formulary: Use the formulary lookup at humana.com or call HPS at 1-800-379-0092 to confirm tier placement and PA requirements for specific medications
3. Ask about Medicare GLP-1 Bridge eligibility: Call Humana at 1-800-448-6262 or CMS at 1-800-633-4227 to confirm whether your MAPD plan participates and your eligibility
4. Contact your provider’s office: Your prescribing provider can run a benefits verification and initiate PA on your behalf via Availity or humana.com/providers
5. Verify telehealth coverage: Confirm whether telehealth weight management visits are covered under your specific Humana MA plan for WV members

Important: Humana MA Is Not Medicaid

Disclaimer: Humana Medicare Advantage is a federally regulated private health plan for Medicare-eligible individuals (typically age 65+, or with qualifying disability). It is not the same as West Virginia Medicaid (Mountain Health Trust), which is a separate state-federal program administered by the WV Department of Health and Human Resources (DHHR). WV Medicaid is for low-income residents and is not administered by Humana in West Virginia. For WV Medicaid questions, contact WV DHHR at 1-800-642-8589.

Frequently Asked Questions

Does Humana Medicare Advantage cover Wegovy in West Virginia?

Traditionally, Medicare Part D excluded weight loss drugs. However, as of July 1, 2026, eligible Humana MAPD members may access Wegovy at $50/month through the CMS Medicare GLP-1 Bridge program — outside the standard Part D formulary. Contact Humana at 1-800-448-6262 or CMS at 1-800-633-4227 to verify your plan’s participation and your eligibility.

Does Humana cover Zepbound (tirzepatide) for weight loss in WV?

Zepbound (tirzepatide for weight loss) may be accessible to eligible Humana MAPD members at $50/month through the Medicare GLP-1 Bridge program starting July 1, 2026. Note that Mounjaro — which contains the same active ingredient but is indicated for type 2 diabetes — is a separate medication with different coverage criteria.

Does phentermine require EPCS in West Virginia?

Yes. Phentermine is a Schedule IV controlled substance. Under W. Va. Code § 60A-4-403a, West Virginia requires electronic prescribing (EPCS) for all controlled substances, including Schedule IV. Prescribers must use a DEA-compliant EPCS system to prescribe phentermine in WV. Paper prescriptions are generally not permitted for outpatient phentermine prescribing in this state.

Does West Virginia’s mental health parity law cover weight loss treatment?

No. West Virginia’s mental health parity statute (W. Va. Code § 33-25-8r et seq.) covers mental health and substance use disorder benefits only. It does not govern weight loss treatment coverage. Weight loss coverage for Humana MA members is governed by CMS 42 CFR Part 422 and your plan’s Evidence of Coverage, not by WV state parity law.

Can I appeal a denied weight loss medication PA under Humana MA?

Yes. Under CMS rules, you have the right to request a Medicare Advantage coverage determination, redetermination, Independent Review Entity (IRE) review, ALJ hearing, and further appeals. Timelines: standard redetermination 7 days; expedited 72 hours; IRE standard 60 days. Contact Humana at 1-800-448-6262 or CMS at 1-800-633-4227 for help with appeals.

Does WV SB 267 apply to Humana Medicare Advantage?

No. WV SB 267 (2024), which requires electronic PA submission via Availity for state-regulated commercial insurers, does not apply to Humana Medicare Advantage. MA plans are federally regulated under 42 U.S.C. § 1395w-26(b)(3), which preempts state insurance mandates. Humana MA members and providers should submit PA requests via Availity or humana.com/providers — the legal basis is federal MA requirements, not WV SB 267.

Key Contacts

• Humana Member Services: 1-800-448-6262 | humana.com
• Humana Pharmacy Solutions (HPS): 1-800-379-0092
• Humana Provider/PA Portal: humana.com/providers
• Availity (PA submission): availity.com
• CMS Medicare Helpline: 1-800-633-4227 | medicare.gov
• WV Insurance Commissioner: 1-888-879-9842 | wvinsurance.gov (limited MA jurisdiction — direct benefit disputes to CMS)
• WV SHIP (State Health Insurance Assistance Program): 1-877-987-4463 — free Medicare counseling for WV residents
• WV DHHR (Medicaid — separate program): 1-800-642-8589
• SAMHSA Helpline: 1-800-662-4357
• 988 Suicide and Crisis Lifeline: Call or text 988

Disclaimer: Coverage information in this guide is based on publicly available information and is provided for educational purposes only. Coverage may vary significantly by specific Humana Medicare Advantage plan, formulary year, and individual member circumstances. Klarity Health is not affiliated with Humana or CMS. Always verify your specific benefits directly with Humana (1-800-448-6262), HPS (1-800-379-0092), or CMS (1-800-633-4227) before beginning treatment. This content does not constitute medical or legal advice.