Getting coverage for GLP-1 agonist medication

Yes, I'm less nauseous when I use my thigh.

Hi @michellejack1 - I noticed you were taking semaglutide (Wegovy), which I also took. I had good luck with weight loss and lost 53 pounds, but I had some real challenges with chronic diarrhea, nausea, vomiting and abdominal cramping. I finally asked my doctor about switching to tirzepatide (Zepbound). She did switch me, but about the time I got to the top dose, my insurance stopped paying. I'd reached the max. I only lost 1 pound on tirzepatide (Zepbound). I went with nothing for a while and watched my weight slowly slide upward, sadly, and then was put on phentermine and topiramate. That sort of held me in place weight-wise, but allowed me to gain just a bit.

This calendar year my insurance will cover semaglutide (Wegovy) again, so I'm going to go back on with much attention to preventing/treating side effects and making sure I'm not going up to the next dosage when I can't even handle a lower one.

Are you continuing on the semaglutide (Wegovy), using another strategy, or are you now at goal?

Your Dr needs to write a prior auth . I noticed you have sleep apnea Zepbound is fda approved for sleep apnea . If you take Zepbound make sure you Dr it is Zepbound is for sleep apnea . Most insurance companies don’t cover anything for weight loss

It took me a bit for my insurance to cover my Zepbound, I have moderate-severe apnea with no comorbidities so I was given Zepbound,my husband has low to moderate apnea and will not cover him for Zepbound, now he’s got 2 comorbidities so I’m going to reach out to see if they will get on board and help. And you are correct, if you mention anything about being overweight they’ll deny you.

@barbsbaileyboo
UPDATE
Our insurance for my husband will only pay for Zepbound if his overnight test for sleep apnea is low-moderate, that’s it!!

@barbsbaileyboo
Opps, what I meant to say was, insurance Wii pay if his apnea test is moderate-severe, sorry!

@turberg what strength of Zepbound is always out of stock? I’m on 5mg and have had no problems getting it.

Hi Michelle, I’m sorry you’re having this trouble. I too had many problems obtaining Wegovy. With everything describes, you meet multiple indications for coverage. If your doctor hasn’t submitted a prior authorization, I would definitely do that. Otherwise, you can appeal the insurance decision. Either do this directly with the insurance, or you can request an external review, where an outside medical professional will have the final say. This is what I did and won. Write a compelling argument, detailing the conditions you have AND the trouble it causes you. The link is at the end to the page. I hope you can get this to work. You really have to be persistent and keep looking for avenues - you’ll get it eventually! Let me know if you have any more questions or anything else.
https://www.healthcare.gov/appeal-insurance-company-decision/appeals/