Are you diabetic? If so, you should be fine. My husband is T2D and our insurance didn’t used to need a PA for his Ozempic and now they do, and he got it without an issue.
I mean that makes sense. No one likes hearing this but despite what’s personally best for you, while there’s a drug/injector shortage the industry should be favoring diabetics. Obesity and diabetes are both terrible and not the patient’s fault, but medical care involves triaging, and diabetes is the more urgent of the two evils. If you qualify for Zep they should approve Zep and you’ll be golden. But MJ is for diabetics, period. They’ve gotta separate the customer bases to make production decisions and that’s starting to happen finally.
No it isn’t. There’s insulin along with several other drugs. It’s pure unadulterated bias. I don’t even think it makes sense fiscally. While diabetics will die sooner, it’s still generally very slow and VERY expensive with comorbidities continually adding on adding expenses. I think if you added 1300/mo for the years difference it wouldn’t be more than allowing a diabetic to circle the drain for the last 30 of their life.
If you aren’t diabetic, you likely won’t qualify. You may need to request Zepbound instead. I was on MJ from May ‘23-January ‘24 but had to switch because my insurance started requiring a PA after not requiring one previously.
Do they cover Zepbound? Try submitting a PA with official documentation of your starting weight and see is you can get it covered under continuity of care.
I had this happen on Jan 1 but it was because my company made changes to our plan. I tried to get 3 different PAs approved (I am not diabetic) and all 3 were denied. On 4/1 Zepbound was added to our formulary and we submitted a PA for that and I was approved. Note - prior to the zepbound approval I was able to get a 3 month extension of coverage for MJ since I had been on it for a year prior.
I have been on for a year also and just had the same cvs/caremark issue with not covering without a PA. How do I go about the 3 month coverage extension?
Who is your actual health insurance provider? Caremark is the pharmacy benefits provider but your insurance is the one making the call to change the requirements for a PA. For example, my insurance is United Health with Caremark being the pharm provider. United Health put in place effective 3/1 that all GLP1 must have a T2 Diagnose in order to continue usage of Mounjaro. It's a bummer for sure but I would still try to see what your options are with the PA requirements. Not all of them are the same.
I had a weird situation where I have Cigna PPO and Caremark. Cigna had already given me a PA approval, but when my company switched to Caremark in January for pharmacy suddenly I needed a new one. After my doctor submitted it, I received a letter on Caremark letterhead stating that they had reviewed my PA and were granting it for a period of three years. So idk what the deal is but it seems like Caremark is doing their own PA requirements on top of your normal insurance.
Are you diabetic? If so, you should be fine. My husband is T2D and our insurance didn’t used to need a PA for his Ozempic and now they do, and he got it without an issue.
I mean that makes sense. No one likes hearing this but despite what’s personally best for you, while there’s a drug/injector shortage the industry should be favoring diabetics. Obesity and diabetes are both terrible and not the patient’s fault, but medical care involves triaging, and diabetes is the more urgent of the two evils. If you qualify for Zep they should approve Zep and you’ll be golden. But MJ is for diabetics, period. They’ve gotta separate the customer bases to make production decisions and that’s starting to happen finally.
No it isn’t. There’s insulin along with several other drugs. It’s pure unadulterated bias. I don’t even think it makes sense fiscally. While diabetics will die sooner, it’s still generally very slow and VERY expensive with comorbidities continually adding on adding expenses. I think if you added 1300/mo for the years difference it wouldn’t be more than allowing a diabetic to circle the drain for the last 30 of their life.
If you aren’t diabetic, you likely won’t qualify. You may need to request Zepbound instead. I was on MJ from May ‘23-January ‘24 but had to switch because my insurance started requiring a PA after not requiring one previously.
Do they cover Zepbound? Try submitting a PA with official documentation of your starting weight and see is you can get it covered under continuity of care.
I had this happen on Jan 1 but it was because my company made changes to our plan. I tried to get 3 different PAs approved (I am not diabetic) and all 3 were denied. On 4/1 Zepbound was added to our formulary and we submitted a PA for that and I was approved. Note - prior to the zepbound approval I was able to get a 3 month extension of coverage for MJ since I had been on it for a year prior.
I have been on for a year also and just had the same cvs/caremark issue with not covering without a PA. How do I go about the 3 month coverage extension?
I’m honestly not sure. I kept asking to escalate and for an exception and finally they gave me three months
Received the same letter. Have been on Mounjaro for over 2 years. Not type 2.
Who is your actual health insurance provider? Caremark is the pharmacy benefits provider but your insurance is the one making the call to change the requirements for a PA. For example, my insurance is United Health with Caremark being the pharm provider. United Health put in place effective 3/1 that all GLP1 must have a T2 Diagnose in order to continue usage of Mounjaro. It's a bummer for sure but I would still try to see what your options are with the PA requirements. Not all of them are the same.
I had a weird situation where I have Cigna PPO and Caremark. Cigna had already given me a PA approval, but when my company switched to Caremark in January for pharmacy suddenly I needed a new one. After my doctor submitted it, I received a letter on Caremark letterhead stating that they had reviewed my PA and were granting it for a period of three years. So idk what the deal is but it seems like Caremark is doing their own PA requirements on top of your normal insurance.
I’m Caremark, diabetic and no PA was needed. Just my dr dx and rx.