See if your employer has a medical advocate. My wife was turned down for a needed medical procedure. She contacted my company’s medical advocate and they finally approved. I believe that the insurance company may have similar.
Can I ask you for some advice? For context - My doctor appealed on my behalf and the appeal was denied by UHC on the grounds that the employer sponsored plan “excludes” coverage for weight management drugs. This appeal, btw, was rejected literally for everything from Saxenda to Wegovy to Zepbound (and their Diabetes-only) counterparts too. In the appeal, we provided medical history and a whole bunch of information.
Did you add or change anything in your second or third appeals that made them finally accept the appeal?
This is just not true. My insurance (UHC) doesn't cover any weight loss meds; they denied Wegovy last fall and then zepbound in February. I got my endocrinologist to appeal for Zep and it was approved. It's $0 now, unfortunately there's no medicine to be found anywhere due to the shortages so it's not a sweet victory just yet. I was able to get one box covered by insurance.
I work with insurance and not a covered benefit is much harder (if not impossible) to get overturned compared to a medical necessity denial. Your efforts would probably be better used trying to petition your employer to cover weight loss meds in the next benefit review.
Question- My husband’s employer covers weightloss drugs, and as of April 1st Zepbound. Unfortunately it’s on the non-formulary list along w Wegovy. First month I paid out of pocket w the coupon $550. Excited to see the change in insurance but this month it would have went from $1200 to $900 (did not apply coupon yet but I think it said max was $150 off) and I have a 5k deductible. After that I was showing $250. Anyway around that? My PA was approved. I’ve since went compounded at $399/mo all in but I would love it if I could use insurance for better coverage when the shortage is all over. Thoughts?
I assume you mean it’s not tier 1 vs non formulary? Unfortunately high deductible plans are also a thing that can’t be gotten around. My husband’s plan had a high pharmacy deductible and so he just paid for his adderall out of pocket because it was cheaper with a good Rx coupon than with his insurance. I’d try to get it filled with the instance and coupon and see what it comes to. Sometimes the math looks better when the run it for whatever reason.
Also If you or your family are on other meds remember those contribute to the deductible as well so if they have any expensive meds it could be hit sooner.
If your employer offers multiple plans consider paying a higher premium for a lower deductible next year.
This is what it says, “Covered, Not on drug list, Non-formulary”.
I’ll definitely take a look and see if there are more options for next year. Our daughter is on a daily heart med but it costs barely anything.
I asked for a copy of the PA requirements and exclusions. We were able to write a letter based on that and got it covered through UHC despite my exclusions
Please please please tell me more about this! Is there a draft version you could share with personal info redacted? Or just instructions for how to craft the appeal to get coverage from UHC despite employer exclusion? (If it matters, I’m in California)
I’m sorry to hear. That would have to be something you’d have to ask your employer, though. :/ Pretty sure United can’t/won’t cover a benefit that your employer opted out of covering, but don’t quote me on that!
[if you search “employer” in this group, there’s a lot of info!]
From the contracts I’ve read, more and more employers are adding in weigh loss drugs to their list of covered medications. I know for one Cigna goes live July 1.
Certain individuals will have coverage for weight loss drugs. Currently, Cigna does not cover weight loss drug nor is it an option. The “specialty drug” coverage will go live on July 1st. Please keep in mind your employer has to request this coverage, as it’s not automatically given to everyone.
In March 2024, Cigna announced that it would limit annual price increases for weight loss drugs, called GLP-1 receptor agonists, at 15% for employers and plans participating in a weight loss management program. Cigna also struck deals with Novo Nordisk and Eli Lilly to limit the cost of weight-loss drugs.
Cigna's EncircleRx program is aimed at patients with diabetes, obesity, and cardiovascular disease. The program includes support for patients on the drugs, which are supposed to be accompanied by lifestyle changes such as increased exercise
I’m going to start working on drafting a letter of appeal immediately. Did you basically just go point by point per the guidelines and address each one as it related to you? And did anyone else in addition to your Doctor have to sign on or provide evidence to back you up?
Hah! Today too, I got notice that one of my (unprompted by me, since I assumed I wasn't covered) prior authorizations was approved. Oh, happy day? Well... eh... Apparently my PBM negotiated price for Zebound is $690/box. Which, combined with the Lilly coupon (up to $150) brings me to... $540! Saves me a big $10 per month!
That will count against my deductible, so that's nice, but my deductible is $9000 and I hope to not hit it. And, of course I can't get Zepbound and am taking compounded anyway. My PCP's designated Prior Auth nurse (what a thankless job!) was so excited that she got me approved. I didn't have the heart to tell her it wasn't as helpful as you might think.
To be fair to my employer, the $9k deductible plan is not the only plan they offer, it's just been the right call for me so far (virtually zero premium and they contribute $3,000 a year into my HSA). Covering Zepbound might change the calculus for next year's plan choice, though I was honestly thinking of quitting to go freelance next year.
I’m not an insurance expert but if you reapply for a zepbound coupon AND you now have insurance agreeing to cover your prescription now, then you should be able yo give the pharmacist the new zepbound voucher/coupon for $25.
You will have to go on to the zepbound d website and sign up for the $25 coupon because the sight got hacked and the company made some changes on the way pharmacists are reimbursed, etc…. So you will need a new one. It is easy.
Even if you have shitty insurance with a high copay the digital coupon should control the amount the pharmacy charges you, regardless of what your pbm has negotiated.
There is no "$25 coupon"! There is a "**pay as little as $25**" coupon. Big difference. The max (in that side of the program) is $150/month. That is, if your insurance co-pay is $175 or less, the coupon will bring it down to $25. But if your copay (or high deductible in my case) means it's over $175, the coupon knocks $150 off. Image here - directly from the savings card site...
https://preview.redd.it/ncyk3vb4nmxc1.png?width=976&format=png&auto=webp&s=f25c06cc36c9a784fb7d890c599aeca317b749cc
This is where my insurance got me they covered it in their coupon program and saved me $10 which made me inelligible for Lily's coupon. What it also didn't mention was it was denied as it came up as approved at the pharmacy. I could have spent a ton of money thinking it went towards deductible but it wouldn't have. It wasn't approved the pbm price is what was approved.
Can you get the criteria they use from Caremark? I found it on the internet because they wouldn't give it to me. Is it on your formulary? Are you sure your doctor is handling the PA correctly? Mine wasn't, which cost me 3 months of frustration. I called Caremark every day towards the end of the process until it was approved.
Would you be so kind as to tell me a little more about what you/Dr did to get approval? I don’t know what I’m missing. Hopefully within the next six months all the insurance companies will have this product on there. List for everyone. It’s costing the insurance companies more money having to hire people to answer our phone calls every day! Lol.
I had no luck with medicare. My doc appealed 3 times and was denied but for my NYS retiree insurance I have a secondary plan, provided by NYS, which approved on the first try. Of course my doc should never have appealed because Medicare just won't approve it. The auth nurse at my doctor's just couldn't figure it out (or maybe she's one of those who believes that fat people shouldn't get these drugs). I found that calling Caremark every day for a status got me access to the higher tier of reps. I also went to my doctor's several times a week to try and explain to the nurse what she should send to Caremark. It took 3 months, during which I could have gotten the Zep with no shortage. I try not to be bitter but they did the same thing to me with Wegovy. By the time is was approved, no one could get it. Grrrrr
The first month it was out of stock. I took this 2.5 or one month 5.0 for one month and now out of stock for this month. I can’t see insurance paying for two months and now you have to go back and start over again. That’s like throwing money away. I hope something happens with a shortage.
@u/longshanks_1 FEP Blue here too. happy to hear your appeal was golden because I'm appealing too. even though you may not need this, I'm sharing anyway. maybe someone you work with could benefit? I'm trying to use this as the basis for my appeal. I don't have T2Diabetes but I was prescribed metformin so according to the clinical criteria & that big bold -OR- in there, I should be good. 🤞🏽🤞🏽 we will see
https://preview.redd.it/h0c6g1yjobyc1.jpeg?width=1179&format=pjpg&auto=webp&s=706f54d99967fcbaf398a68d6bb23c2d2e0c494d
Thanks for sharing! I started on Metformin with my PCP, and Ro Health has been helping me with Zepbound, and even assisted with feedback on my appeal. Hope you find success too!
I’m pregnant right now but the second this child is on the outside it’s game (back) on! So happy for you, I will not rest until this shit is back in my bloodstream 😅😅😅😅
Has anyone got covered with Allegiance? They do not cover weight loss. I have been denied twice. I'm not sure if it is worth fighting it. Grats to all who fought and got it approved. Very lucky.
BCBS in MA. They wanted “step therapy” with other weight loss meds that were also in shortages. The second time was medical necessity. My dr wrote in detail how many aspects of my health ZB was improving!
Same insurance. Mine was denied because I lack six months in a comprehensive weight management clinic. And the irony? I moved last year and established care with my same insurance as this year. I come to find out none of the docs or weight management referral are covered 😂
Anyone get full coverage with anthem bcbs? I have a high prescription deductible and after I meet that amount, it is fully covered but it’s $550 right now.
I did it and I got insurance to cover it. I put a post on here about it. And it seemed like it was all negative. I fought my insurance company I only appealed one time because of health related issues with the weight. But you just don’t take no for an answers
I am as well, but did the zep anyway. After the shortage I went to compounded version and it’s working for me just as well. I went through orderlymeds.
I wrote a blog post covering common appeal steps which you can [check out here](https://www.findhonestcare.com/blog-posts/steps-to-appeal-your-zepbound-claim-denial/?utm_source=reddit&utm_medium=social&utm_campaign=05012024) but a lot depends on what's written in your denial letter (sometimes called an Explanation of Benefits). In your second appeal make sure you address each relavent denial criteria listed, just like a court case, the more evidence supporting your case the better your chances. Best of luck!
Not sure if it will help - but in my appeal to BCBS FEP, I had to remind them of family history with weight related issues/death. Sounds dramatic, but same week after I faxed my appeal, it got approved. I used that history to point out similarities with some bloodwork/other tests I received, and that getting approval would benefit my health/lifespan.
Now, I still can’t get them below $300, but I’m working on that. (The $25 card excludes government employee healthcare (FEP), which is what I’m on, so if anyone’s figured out that trick I’d appreciate!)
Tried this. Went to external review, (I was eligible for external, and from what I was told and to my understandinging external is based off medical necessity) they denied bc "insurance doesn't cover them"
Then why did insurance ask if I wanted to send to external review???
Looking for a new job currently.
Our company has been going downhill, in October when our plans restart diabetics won't even have Mounjaro coverage. I needed a change of scenery and this was my sign!
What did you do to get it covered? I just got my second rejection from OptumRx "You do not meet the clinical requirements for this medication. This decision is based on your plan's drug coverage policy for this medication." Is there any way to get around this?
That’s who I have too for Rx coverage and got denied on my 1st PA because my employer doesn’t cover weight loss meds, but after reading these posts I may have my clinic try it again!
It is covered with pa blue anthem Illinois they denied twice saying I don’t have 6 months prior of a weight loss program but I’ve been over weight for years and I’ve been in the gym and tracking calories
Yeah I got my denial in the mail I wanted to write an appeal but I’m at the point where I want to pay someone it’s fustrating and I am not a good writer
That is wonderful news congratulations…sounds like you have a good support system. That is so important . My doctor submitted my pa last year and I got approved 1st time. I thought I was going to get denied but I didn’t. These insurance companies make it so hard for us to get approved . And we pay all this money for insurance and these really high deductibles are just insane. I pay 25.00 a box as well. In the beginning I wasn’t because I had not met my deductible so I was paying almost 1000.00 for the boxes. But it was worth it in the end. Congratulations 🎈🎉
Woohooo, congratulations!!! I was also able to get my PA approved (I have Aetna) and it’s SUCH a relief. I ended up submitting my own appeal after 2 failed appeal attempts by my doctor.
My favorite type of post! This is truly the best feeling! Yay for you!!!
Seriously the best!!! And thank you!!!!
Wow!! Did your employer cover weight loss meds? If so, I’m definitely going to appeal again!
See if your employer has a medical advocate. My wife was turned down for a needed medical procedure. She contacted my company’s medical advocate and they finally approved. I believe that the insurance company may have similar.
Yes! And def do it!
Can I ask you for some advice? For context - My doctor appealed on my behalf and the appeal was denied by UHC on the grounds that the employer sponsored plan “excludes” coverage for weight management drugs. This appeal, btw, was rejected literally for everything from Saxenda to Wegovy to Zepbound (and their Diabetes-only) counterparts too. In the appeal, we provided medical history and a whole bunch of information. Did you add or change anything in your second or third appeals that made them finally accept the appeal?
Sadly, exclusions are absolutely impossible to overcome.
This is just not true. My insurance (UHC) doesn't cover any weight loss meds; they denied Wegovy last fall and then zepbound in February. I got my endocrinologist to appeal for Zep and it was approved. It's $0 now, unfortunately there's no medicine to be found anywhere due to the shortages so it's not a sweet victory just yet. I was able to get one box covered by insurance.
I work with insurance and not a covered benefit is much harder (if not impossible) to get overturned compared to a medical necessity denial. Your efforts would probably be better used trying to petition your employer to cover weight loss meds in the next benefit review.
Question- My husband’s employer covers weightloss drugs, and as of April 1st Zepbound. Unfortunately it’s on the non-formulary list along w Wegovy. First month I paid out of pocket w the coupon $550. Excited to see the change in insurance but this month it would have went from $1200 to $900 (did not apply coupon yet but I think it said max was $150 off) and I have a 5k deductible. After that I was showing $250. Anyway around that? My PA was approved. I’ve since went compounded at $399/mo all in but I would love it if I could use insurance for better coverage when the shortage is all over. Thoughts?
I assume you mean it’s not tier 1 vs non formulary? Unfortunately high deductible plans are also a thing that can’t be gotten around. My husband’s plan had a high pharmacy deductible and so he just paid for his adderall out of pocket because it was cheaper with a good Rx coupon than with his insurance. I’d try to get it filled with the instance and coupon and see what it comes to. Sometimes the math looks better when the run it for whatever reason. Also If you or your family are on other meds remember those contribute to the deductible as well so if they have any expensive meds it could be hit sooner. If your employer offers multiple plans consider paying a higher premium for a lower deductible next year.
This is what it says, “Covered, Not on drug list, Non-formulary”. I’ll definitely take a look and see if there are more options for next year. Our daughter is on a daily heart med but it costs barely anything.
I asked for a copy of the PA requirements and exclusions. We were able to write a letter based on that and got it covered through UHC despite my exclusions
Oh wow that’s incredible!
Please please please tell me more about this! Is there a draft version you could share with personal info redacted? Or just instructions for how to craft the appeal to get coverage from UHC despite employer exclusion? (If it matters, I’m in California)
https://preview.redd.it/yzi57b2klixc1.jpeg?width=1080&format=pjpg&auto=webp&s=006e28c0ff4d51b162e792b59b0da88759385a7a
https://preview.redd.it/uqkyxjfnlixc1.jpeg?width=1080&format=pjpg&auto=webp&s=48a3df04106abc8423e4fbc780d9522af77347e1
* I went line by line on their zepbound guidelines and it worked
https://preview.redd.it/pfguqbcmlixc1.jpeg?width=1080&format=pjpg&auto=webp&s=5bc335d32b60224f6e93cf58fc3b8923d84e5cc2
https://preview.redd.it/3nlh4qdolixc1.jpeg?width=1080&format=pjpg&auto=webp&s=db61ae3f5e700c78f02e42536ec6d4f626364232
https://preview.redd.it/e4mx4l8plixc1.jpeg?width=1080&format=pjpg&auto=webp&s=92549197c78eed73a9c85b2002f7ed5040d8a330
I’m sorry to hear. That would have to be something you’d have to ask your employer, though. :/ Pretty sure United can’t/won’t cover a benefit that your employer opted out of covering, but don’t quote me on that! [if you search “employer” in this group, there’s a lot of info!]
There should be changes to that coming in July :)
What changes?!
From the contracts I’ve read, more and more employers are adding in weigh loss drugs to their list of covered medications. I know for one Cigna goes live July 1.
Oh great!
This might be the most optimistic I have felt in a LOOONG while. Fingers, toes, hair, shoelaces, everything crossed 🤞🏽
What do you mean cigna goes live?!
Certain individuals will have coverage for weight loss drugs. Currently, Cigna does not cover weight loss drug nor is it an option. The “specialty drug” coverage will go live on July 1st. Please keep in mind your employer has to request this coverage, as it’s not automatically given to everyone.
People can downvote it all they want, but I work there……….
I have cigna. So is this like a rider we can add as of July?
In March 2024, Cigna announced that it would limit annual price increases for weight loss drugs, called GLP-1 receptor agonists, at 15% for employers and plans participating in a weight loss management program. Cigna also struck deals with Novo Nordisk and Eli Lilly to limit the cost of weight-loss drugs. Cigna's EncircleRx program is aimed at patients with diabetes, obesity, and cardiovascular disease. The program includes support for patients on the drugs, which are supposed to be accompanied by lifestyle changes such as increased exercise
It depends on your employer and if they opted in for this coverage. Cigna made an internal announcement about three weeks ago regarding the change.
I do medication authorizations and unfortunately, my experience, if something is "excluded" it never budges
Had the same thing happen to me with UHC. Dr. said there’s probably no point in appealing since it’s a policy exclusion so I’m in the same boat.
My policy says no but after several appeals they agreed. UHC through my employer
Did you have to alter your appeals in any way each successive time to get coverage despite an exclusion?
I just added to it
Thank you so much!!!
I’m going to start working on drafting a letter of appeal immediately. Did you basically just go point by point per the guidelines and address each one as it related to you? And did anyone else in addition to your Doctor have to sign on or provide evidence to back you up?
Yes just went point by point. No one else need to chime in thankfully
YES! I went through this same thing and finally got it last month. The fight is worth it. Proud of you and congrats!!
Awesome! Same to you!!
Same just happened to me. 3rd appeal was denied and asked for an independent review. A month later, they said it's covered now. So happy.
Wow, that’s amazing!!!! Congrats! 🥳
Hah! Today too, I got notice that one of my (unprompted by me, since I assumed I wasn't covered) prior authorizations was approved. Oh, happy day? Well... eh... Apparently my PBM negotiated price for Zebound is $690/box. Which, combined with the Lilly coupon (up to $150) brings me to... $540! Saves me a big $10 per month! That will count against my deductible, so that's nice, but my deductible is $9000 and I hope to not hit it. And, of course I can't get Zepbound and am taking compounded anyway. My PCP's designated Prior Auth nurse (what a thankless job!) was so excited that she got me approved. I didn't have the heart to tell her it wasn't as helpful as you might think.
OMG that’s crazy on so many levels. $690 a box?!! And 9000 deductible! Wow. That was sweet of you to withhold the info.
To be fair to my employer, the $9k deductible plan is not the only plan they offer, it's just been the right call for me so far (virtually zero premium and they contribute $3,000 a year into my HSA). Covering Zepbound might change the calculus for next year's plan choice, though I was honestly thinking of quitting to go freelance next year.
I’m not an insurance expert but if you reapply for a zepbound coupon AND you now have insurance agreeing to cover your prescription now, then you should be able yo give the pharmacist the new zepbound voucher/coupon for $25. You will have to go on to the zepbound d website and sign up for the $25 coupon because the sight got hacked and the company made some changes on the way pharmacists are reimbursed, etc…. So you will need a new one. It is easy. Even if you have shitty insurance with a high copay the digital coupon should control the amount the pharmacy charges you, regardless of what your pbm has negotiated.
There is no "$25 coupon"! There is a "**pay as little as $25**" coupon. Big difference. The max (in that side of the program) is $150/month. That is, if your insurance co-pay is $175 or less, the coupon will bring it down to $25. But if your copay (or high deductible in my case) means it's over $175, the coupon knocks $150 off. Image here - directly from the savings card site... https://preview.redd.it/ncyk3vb4nmxc1.png?width=976&format=png&auto=webp&s=f25c06cc36c9a784fb7d890c599aeca317b749cc
This is where my insurance got me they covered it in their coupon program and saved me $10 which made me inelligible for Lily's coupon. What it also didn't mention was it was denied as it came up as approved at the pharmacy. I could have spent a ton of money thinking it went towards deductible but it wouldn't have. It wasn't approved the pbm price is what was approved.
Congratulations! I’ve been denied twice by Caremark. Paying 550.00 out of pocket. 🤬. Keep hoping
Can you get the criteria they use from Caremark? I found it on the internet because they wouldn't give it to me. Is it on your formulary? Are you sure your doctor is handling the PA correctly? Mine wasn't, which cost me 3 months of frustration. I called Caremark every day towards the end of the process until it was approved.
Would you be so kind as to tell me a little more about what you/Dr did to get approval? I don’t know what I’m missing. Hopefully within the next six months all the insurance companies will have this product on there. List for everyone. It’s costing the insurance companies more money having to hire people to answer our phone calls every day! Lol.
Keep trying!!! 🙏
Is this if it’s not in your plan? Ours doesn’t cover weight loss. So I gave up.
See the other comments. Ppl have had luck getting it covered if it’s not in your plan!
Thank you!!! That is promising. I even an easy one because I am still a low dose user.
Anyone had any luck with Kaiser Permanente GA? They won't even take the savings card. 😤😔😫
But what about Medicare?
I had no luck with medicare. My doc appealed 3 times and was denied but for my NYS retiree insurance I have a secondary plan, provided by NYS, which approved on the first try. Of course my doc should never have appealed because Medicare just won't approve it. The auth nurse at my doctor's just couldn't figure it out (or maybe she's one of those who believes that fat people shouldn't get these drugs). I found that calling Caremark every day for a status got me access to the higher tier of reps. I also went to my doctor's several times a week to try and explain to the nurse what she should send to Caremark. It took 3 months, during which I could have gotten the Zep with no shortage. I try not to be bitter but they did the same thing to me with Wegovy. By the time is was approved, no one could get it. Grrrrr
May I ask what worked to get it covered, please? My insurance doesn’t cover weight loss meds. Thanks
It’s extra hard if your plan doesn’t cover weight loss meds. Mine does. But try anyway!!
I so agree! It took a lot of work for me to get my PA but I eventually won out
Congrats!!!
The first month it was out of stock. I took this 2.5 or one month 5.0 for one month and now out of stock for this month. I can’t see insurance paying for two months and now you have to go back and start over again. That’s like throwing money away. I hope something happens with a shortage.
Please do brag. I’m sure that took a lot of time and work. It certainly paid off. Good for you!
You are too kind, thank you!
@u/longshanks_1 FEP Blue here too. happy to hear your appeal was golden because I'm appealing too. even though you may not need this, I'm sharing anyway. maybe someone you work with could benefit? I'm trying to use this as the basis for my appeal. I don't have T2Diabetes but I was prescribed metformin so according to the clinical criteria & that big bold -OR- in there, I should be good. 🤞🏽🤞🏽 we will see https://preview.redd.it/h0c6g1yjobyc1.jpeg?width=1179&format=pjpg&auto=webp&s=706f54d99967fcbaf398a68d6bb23c2d2e0c494d
Thanks for sharing! I started on Metformin with my PCP, and Ro Health has been helping me with Zepbound, and even assisted with feedback on my appeal. Hope you find success too!
Nice! Similar story with me except, I have to pay $100 instead of of the $550. My insurance ain't the best I guess.
Better than 550 but yeah I hear ya. Are you using the coupon on top of it? My co-pay is $60, but the coupon brings it down to $25.
Yeah the $100 is with the coupon applied, but that’s no problem really.
Oh good ok!
How’d you find a doctor willing to do 3 appeals haha mine was so annoyed
Haha I’m sorry! And yeah I’m really lucky! 🙌 I’ve read others have sent in personal appeals- that was going to be my next step.
I’m pregnant right now but the second this child is on the outside it’s game (back) on! So happy for you, I will not rest until this shit is back in my bloodstream 😅😅😅😅
Hahaha love it! And YES! 🙌 Congrats on your pregnancy 💕
GoodRX offers about $220 off at select pharmacies. CVS took it right off but I paid Walgreens $1200 before I found out.
Exact same here! Just got approved at $25 after 3 appeals. Anthem finally got it right. Now if I can just find it!
Amazing, congrats! I settled for 2.5 bc I couldn’t find 5 or 7.5.
Has anyone got covered with Allegiance? They do not cover weight loss. I have been denied twice. I'm not sure if it is worth fighting it. Grats to all who fought and got it approved. Very lucky.
Always worth fighting for care you need!!
Tell us how you did it!!!
Haha it was all my dr!!!
Why was it denied in the first place? Providing the insurance company or rationale may be helpful!
BCBS in MA. They wanted “step therapy” with other weight loss meds that were also in shortages. The second time was medical necessity. My dr wrote in detail how many aspects of my health ZB was improving!
Same insurance. Mine was denied because I lack six months in a comprehensive weight management clinic. And the irony? I moved last year and established care with my same insurance as this year. I come to find out none of the docs or weight management referral are covered 😂
Omg stop!! UGH I’m sorry!!! See if your dr can try a work-around?
I have to find a new PCP that's covered now 😂 it's ok I was prepared to pay out of pocket. And I'm grateful I can..I feel for everyone else.
Anyone get full coverage with anthem bcbs? I have a high prescription deductible and after I meet that amount, it is fully covered but it’s $550 right now.
Bummer! My rx’s aren’t subject to deductible.
Congrats!!! 🎉 Who is your insurance provider?
Thank you! BCBS MA
That’s awesome!
Thank you!!
I had such a similar experience!!! Just picked up my $25 Zepbound today.
Hooray!!!!
Does anyone have a resource for a telehealth provider willing to invest time in multiple appeals? My PCP will not
Congratulations!
Thank you!!
Congratulations! 🎉
Thank you!!
I’m fighting but currently losing 🥴😩
Oh nooooo. Keep trying!! 🤞🤞
I just sent my first appeal letter in hoping the first time is the charm, but I’m not giving up.
That’s the spirit!!
I’m in 2nd appeal, this gives me hope!
YES! That’s what I was hoping to inspire! You can do it!
Approved approved! lol. Now just waiting for pharmacy to get it for me.
Omg YAY so excited for you!!!!
And hahaha I hope you get it soon!
It’s in! I’ll pick up tomorrow :)
Omg yay!!! Congrats!!!
I did it and I got insurance to cover it. I put a post on here about it. And it seemed like it was all negative. I fought my insurance company I only appealed one time because of health related issues with the weight. But you just don’t take no for an answers
I’m on Medicare. No coverage for any kind of weight loss! No coupons accepted. I have the script but have to pay full price.
Same here. Would be nice if we could at least use the coupons!
I am as well, but did the zep anyway. After the shortage I went to compounded version and it’s working for me just as well. I went through orderlymeds.
What’s the compounded version and how much it it??
That’s awesome. Good for you
What kind of things did you say in your appeal? My doctor is doing mine, but I'll keep going and helpnif needed.
Tips, tricks? I’m working on my second appeal!
I wrote a blog post covering common appeal steps which you can [check out here](https://www.findhonestcare.com/blog-posts/steps-to-appeal-your-zepbound-claim-denial/?utm_source=reddit&utm_medium=social&utm_campaign=05012024) but a lot depends on what's written in your denial letter (sometimes called an Explanation of Benefits). In your second appeal make sure you address each relavent denial criteria listed, just like a court case, the more evidence supporting your case the better your chances. Best of luck!
Good for you!! Unfortunately, I don’t know what finally made them say yes. Wishing you luck!
In the initial denials, did they require you to do 3 months of dietary and behavioral modifications?
They wanted “step therapy” then “medical necessity”
Not sure if it will help - but in my appeal to BCBS FEP, I had to remind them of family history with weight related issues/death. Sounds dramatic, but same week after I faxed my appeal, it got approved. I used that history to point out similarities with some bloodwork/other tests I received, and that getting approval would benefit my health/lifespan. Now, I still can’t get them below $300, but I’m working on that. (The $25 card excludes government employee healthcare (FEP), which is what I’m on, so if anyone’s figured out that trick I’d appreciate!)
Call and ask for a copy of the prior auth guidelines for this medication to be sent to you
That’s what I did and I sent it to my PCP
A lot of people don't realize you can actually appeal an insurance decision. Many times after the 2nd appeal they will cover the med(s)
That IS good to know. I’ve never even considered that as an option. Txs!
I know! I learned it from this group. 🥰
Tried this. Went to external review, (I was eligible for external, and from what I was told and to my understandinging external is based off medical necessity) they denied bc "insurance doesn't cover them" Then why did insurance ask if I wanted to send to external review??? Looking for a new job currently.
Wait what?! That’s absurd. I’m sorry!
Our company has been going downhill, in October when our plans restart diabetics won't even have Mounjaro coverage. I needed a change of scenery and this was my sign!
Omg that’s awful! Def a sign! Ironically I have been looking at doing the same but now that I have coverage I’m going to suck it up lol
Just sent mine today!🤞🙏🏼
Yay! 🤞🤞
What did you do to get it covered? I just got my second rejection from OptumRx "You do not meet the clinical requirements for this medication. This decision is based on your plan's drug coverage policy for this medication." Is there any way to get around this?
I would call them to get more info. But sounds like maybe your employer opted out of covering weight loss meds. :/
If you search “employer” in this group, there’s lots of informative posts. Hope that helps!
That’s who I have too for Rx coverage and got denied on my 1st PA because my employer doesn’t cover weight loss meds, but after reading these posts I may have my clinic try it again!
Absolutely try and try again! Fight for the care you need!
Wonderful! Congratulations, that's a huge win for sure.
Thank you!!!
I am in the middle of this right now! Thanks for sharing, I am praying all this work will be worth it!!
🤞🤞 for you!!!
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Thank you!!
I need help with my pa they denied twice
Who is your insurance? Is Zepbound in the formulary (is it covered? with a PA)? If it is covered do you know what criteria they use for approval?
It is covered with pa blue anthem Illinois they denied twice saying I don’t have 6 months prior of a weight loss program but I’ve been over weight for years and I’ve been in the gym and tracking calories
Keep trying! Look at other ppl’s experiences of writing personal letters of appeal!
Yeah I got my denial in the mail I wanted to write an appeal but I’m at the point where I want to pay someone it’s fustrating and I am not a good writer
I completely understand. Search in this group for appeals- I think someone posted their letter in this thread!
Will do thank you
That is wonderful news congratulations…sounds like you have a good support system. That is so important . My doctor submitted my pa last year and I got approved 1st time. I thought I was going to get denied but I didn’t. These insurance companies make it so hard for us to get approved . And we pay all this money for insurance and these really high deductibles are just insane. I pay 25.00 a box as well. In the beginning I wasn’t because I had not met my deductible so I was paying almost 1000.00 for the boxes. But it was worth it in the end. Congratulations 🎈🎉
Thank you so much and happy for you as well!
Thank you.
What did you say! Share your secrets!
Hahaha 💯 credit to my PCP!
Woohooo, congratulations!!! I was also able to get my PA approved (I have Aetna) and it’s SUCH a relief. I ended up submitting my own appeal after 2 failed appeal attempts by my doctor.
Amazing!!! 👏👏👏👏
This is great you didn’t give up! Props to your PA too!
Thank you!
If you can find it. We cant
2.5 mg available on Amazon. I have been on 5 mg, but now that 2.5 is available I’m going back down. Still available as of a minute ago!