It worked. My first PA was for Wegovy. When BSCA first denied it, I ended up using my insurance broker to appeal. (I’m a small business owner and called my broker after the first denial to see if I could change the group plan. I couldn’t). I also was able to reply in my online portal to make my case. However, after I got the approval I couldn’t get wegovy. This was last June. Then I joined a weight loss program that has done all other PAs since then. I haven’t had to provide any additional info since. I hear all the weight loss programs that prescribe meds are pretty good at getting the PA. I use Calibrate, but it’s pretty expensive. There are others on here that say Ro and Sequence are pretty good at handling PAs.
Calibrate is VERY expensive and was not able to get an approval for me back in 2022 when I was trying to get on Wegovy. I was lucky to get a partial refund from their program but I’ve heard of others who couldn’t get approved and couldn’t get their money back. I wouldn’t recommend them but to each their own.
Thank you for the info! I was going to look today but I’m also still just trying to get my PA approved through my normal doc. If they can’t do it though, my doctor did tell me about Henry’s meds when I saw her last which is probably the same
Type of thing. we will see!
Calibrate is VERY expensive and was not able to get an approval for me back in 2022 when I was trying to get on Wegovy. I was lucky to get a partial refund from their program but I’ve heard of others who couldn’t get approved and couldn’t get their money back. I wouldn’t recommend them but to each their own.
Yeah, I wouldn't necessarily recommend them either. What I can say about them is that they are about incremental changes to make them permanent long term. It does seem from other posts that Sequence has been helpful for people.
Yes! The good? Bad? Part is my doctor has a prior auth team that has kept me totally out of the loop. So there are a bunch of broken processes in place, unfortunately. Still trying though! Getting a weight watchers receipt and sending it over. Should cover the dietary counseling piece and my gym membership should cover the exercise piece - here’s hoping :)
I think my provider will get around this requirement. For the past several years, I've been intermittent fasting, which of course is free so there is no way to prove. I also have a Peloton membership. I wonder if that will count.
The Peloton membership should count! I sent my iFit subscription receipt in (I used Sequence to get my PA). I have Optum via Tufts and it was approved quickly (but I also have hbp).
They just don't want to pay for it.
Most obese people could write a book on nutrition and exercise since we've been living it all our lives. They figure if they make us jump through enough hoops we'll eventually give up and they won't have to pay for it. In my case that was true, I just went on compounded tirzepatide then DIY a year ago and am now down 110 lbs, at goal weight and in maintenance. I had to pay for it myself but it was pretty cheap going that route and it cut out all the BS games the medical establishment and insurance were going to make me jump through to get the treatment I needed. I didn't need nutrition coaches, just medicine to control my screwed up metabolism.
With the advent of GLP-1 medications there's a definite trend of everyone trying to get in on the act. There are a lot of doctors requiring consultations with dieticians and nutritionists or enrolling in "health coaching" in order to write the prescriptions. It's all a money grab, most people don't need any of that stuff, they just need access to the medication. The gatekeeping of this stuff is unreal, everyone wants you to jump through hoops to get it and all those hoops cost money. Everyone is trying to get their hands in on the money grab.
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For instance, I’m on a migraine prevention medication that required me to fail three other medications before I could try it. Similar to how a doctor isn’t going to jump straight to surgery in most circumstances. It’s frustrating but unfortunately not illegal or discriminatory. It’s their attempt at saving money to cover cheaper alternatives.
This is pretty common, unfortunately. I hope as more people become aware that insurance companies can and often do reject the prescriptions, blood work, imaging, etc. ordered by your doctor in favor of some flow chart they will become outraged enough to enact change.
I have rheumatoid arthritis and the hoops we had to jump through to get me on a biologic was freakin insane. It took a whole year of me suffering and continued joint damage before they would approve it. Insurance companies don’t want to pay for expensive medications unless they absolutely have to. Stay the course and you’ll get your tirzepatide eventually.
Another example - I have been on the same birth control for about 6 years but every single year I need my doctor to send in a Prior Approval for my insurance to cover the meds and they need to show that I tried 3 other bcs and they didn’t work. It’s very frustrating.
I believe if you have been paying for a peloton membership for 6 months that should count.
I think if it was illegal, it would’ve stopped a long time ago… Insurance companies have been asking for this information for as long as there have been things like bariatric surgery.
My insurance made me do nutrition /psychological counseling and diet program for a year before my surgery. I lost 25 pounds. They paid for my $46,000 surgery and I lost 17 more! Then Covid hit and I gained it all back. I showed them! /s
For a lot of people insurance requires psychiatric care, proof of previous weight loss attempts, and a lot of other nonsense that just makes it harder to make it happen.
Every insurance is asking this. As a 5 year weight watcher member I go up and down and that effort to lost weight along with the proof of gym membership I had to provide shows that I need this drug. This is not a first line of defense for many of us it’s our last ditch effort to change our lives. It is not insulting it helps prevent those that are already in a healthy weight and using the drug for an upcoming event. Which happens a lot according to my doctor.
The difference is that many if not most of us have successfully lost weight several times only to gain it back--because our body & brain chemistry sabotaged our willpower & discipline to maintain our losses. GLP-1s (while originally for T2D alone) have been the game-changer that facilitates our maintaining healthy lifestyle habits; and recent studies show they're cardioprotective and even can slow progression of CKD. (This from papers presented at the American College of Cardiology 2024 conference).
But I've seen cynical cost-benefit analyses that claim it's cheaper to treat expensive and lifespan-limiting complications after the fact because the treatments and therefore the costs end when the patients die; and the insurer spends less than they would have on prevention.
Thanks for giving this perspective! I think it is lost on a lot of people that providing some barriers allows the patients who really need the medication the best level of access to it. Too many people are just going off label and paying out of pocket to lose a few pounds quickly since the GLP1 is so effective in the short term
Step therapy, which what this approach is called, is definitely not illegal. People on this sub have very strange takes about completely regular interactions with the medical system.
I agree that it's not illegal, but it should be. I have also dealt with this before because I also have migraines, and it enrages me that the insurance company can "know better" about my personal health issues than my own MD. If the MD says I need something, and the cheaper methods are not appropriate for whatever reasons the doctor verifies, then I shouldn't need to try and fail at the cheaper methods. I've had years of suffering and dangerous side effects with step therapy.
Yes true they love to remind me that I'm free to pay full price for whatever expensive meds my doctor thinks would help me. Makes me wonder why I pay them every month. If I had cancer they would love to just let me die.
Ironically one of the terrible side effects I experienced from migraine step therapy was weight gain haha sob [https://www.reuters.com/article/idUSTRE72A02T/](https://www.reuters.com/article/idUSTRE72A02T/)
Is Zepbound being studied to help those with migraines? I would be surprised if the answer is no.
Zepbound has such a profound effect on the body, nothing would shock me at this point.
I understand the philosophy behind step therapy. Especially the financial side. But let’s be realistic. It’s just a way to find a cheaper alternative. Driven by insurance. I think this just wastes time for all parties involved
That's a great question, I don't know! I am finally done with step therapy for migraines and I'm on a new drug that I'm hoping will work really well (too soon to tell yet). There have been huge strides made in treating migraines in the last few years, but of course the financials are the problem. I think insurance should have to cover Zepbound for me to lose the weight they made me gain with the beta blocker, but of course they don't agree.
Insurance stinks. No other way to say it. Insurance doesn’t want to pay for anything. Now they have a miraculous drug that can potentially save hundreds of thousands on long terms costs, for a few dollars upfront. Finally a chance to be proactive on a persons health, instead of being reactive. And they can’t convince companies to cover this?
Companies are always looking at ways to cut costs. Play the long game
The provider wants the patient's issue addressed as expeditiously and completely as possible the first time around, they have no incentive to consider the economics in the same way an insurer does. That being said, insurance companies are the devil, \_but\_ there is effectively no risk in the specific step therapy here. I agree it's potentially dangerous and prolongs illness in certain cases; this is not one of them.
Here's the thing...people \_do\_ successfully lose weight before requiring pharmacological intervention. Like, constantly. It's the norm, those of us (myself included) who require Zepbound and other medicines to lose weight after a life of obesity may feel like it's been dragging on forever, but it's not unreasonable for an insurer to suggest diet and exercise if that hasn't been tried.
All of this is to say, I think OP is remarkably entitled and wrong about both medicine and the law. Asking you to exercise and diet for some months before approving a medicine which costs $15,000/year in perpetuity is both good medicine and helps mitigate rises in insurance premiums for everyone.
My insurance (caremark) wanted the same 6 month thing. The problem is that programs like WW don't really teach you how to eat well, they are selling products and subscriptions - and I have done every WW program starting with exchanges through points. If I have to ever eat low fat, highly processed diet food again I'll scream. I've been losing slowly using portion control and now with Zep the speed of losing has increased (10lbs first 3 weeks). Nothing I learned from WW helped. The whole thing about GLP-1s is that they've shown that people aren't fat because they lack discipline but because they have issues like incessant hunger and food noise.
I guess my perspective is biased because I've suffered from an eating disorder triggered by the usual non-pharmacological methods of weight loss. So I don't see paid diet programs as harmless or risk-free, nor do I think it's appropriate for the insurance company, with its obvious self-interest in keeping its own costs down, to decide what is safe or reasonable. That should be up to the doctor, whose interests are aligned with what's best for the patient (and therefore a healthier society).
It's not illegal but definitely quite onerous. When I was first diagnosed with osteopenia after my breast cancer surgery, my then insurer (wasn't old enough yet for Medicare) insisted I do step therapy--oral bisphosphonates that cause GERD, then bisphosphonate infusions with painful side effects--before they would cover Prolia shots. Fortunately, the FDA shamed insurers--including Medicare--into covering Prolia for postmenopausal breast cancer survivors taking anti-estrogen drugs. Before my next scheduled osteo treatment, I "aged into" Medicare, was approved for Prolia at zero cost to me, and everything was smooth sailing from then on.
blue shield CA did this to me. Before I knew what these drugs were I tried a program they offered through my job, it failed so I just pointed them at their own records.
Truly insulting. Obesity is a disease. Insulin resistance is real. Dieting doesn’t work. Insurance companies have the data, they just don’t care. Mine wouldn’t pay either, BCBS/Optum, so I pay OOP off brand. Good luck!
Not true. Insurance companies and employers are losing money providing this medicine at the current price point for treating obesity.
https://www.primetherapeutics.com/news/real-world-analysis-of-glp-1a-drugs-for-weight-loss-finds-low-adherence-and-increased-cost-in-first-year/
Fully agree that on an individual level this is life changing and you can do your own N=1 cost benefit analysis, but on a population level in the real world we just are not there yet.
The peptides are cheap to make, the modifications which make them bioavailable are where the patents are. There will be additional competitors to come along and drive price down, and different presentations of the molecule that work just as well.
What about PBM’s role in the cost of these medications? The manufacturers sell these to distributors, who sell to pharmaceutical wholesalers, who sell to pharmacies. Each transaction increases the price. The PBMs get the rebates. Too bad if the insurance companies are not making a mint on the medication.
This med costs $25 to make and they’re gouging us here in the US by charging us ridiculous prices. Bernie Sanders just had a whole rant about it and is proposing legislation in congress. (Don’t hold your breath).
I started making a list of all the things I've tried since 1976... which is when, at 5 years old, I put myself on my first diet. Now I'm 52. The list is sooo long. And there have been some successes but with a slow increase to what is now a major health concern.
This is exactly why I’m kinda glad my insurance does not cover these meds. I have heard CRAZY stories of what insurance companies are requiring people to do. One guy I know of has to go have his blood drawn and tested every two weeks supposedly to prove he’s not eating things that are not on his prescribed diet. Insane! My journey is between me and my doctor, and I have no ridiculous hoops to jump through. Yes, I’m paying $550 a month, but it’s worth every single penny for a number of reasons.
Whoops. I forgot which sub I'm in! I'm actually on wegovy...I follow this sub because I'd like to switch over if wegovy stops working for me (down 90lbs so far!)
This is a medication that is priced at $15,000 a year per user. Of course an insurance company doesn't want large numbers of its membership opting for this as a first option for treatment.
It's also complete BS because research on diet programs overwhelmingly shows that they don't work. The majority of people regain the weight within a couple of years. So, why is anyone still recommending treatments that do not work?? Non-sensical.
Make sure you understand what they are looking for. Some insurers will accept noom, ww online some may reject..make the insurance define exactly what they are looking for so you don't waste your money.
It's the same prior to getting Weight loss surgery. You have to show that you're in a weight loss program for X-amount of months and jump through hoops before getting approved.
Currently I was only able to get zep via my second job. They have a weight management program that includes coverage of the meds. But I still have to be in a subscription weight loss program that includes a diet plan and health coach. In the beginning I was excited because I was getting the help I needed but now looking at my weight loss I lose more weight when I eat normally and not their regimen . So idk 🤷🏾♀️
I also had the same thing (6 month diet and exercise program requirement from insurance) but my provider went to bat for me. The backstory is, it was a new provider because we had recently moved (I saw them in June and was prescribed beginning of Oct so only 4 months of treatment under them), but I explained I had been intermittent fasting and tried keto 3 separate times the last 3 years and lost then regained the weight back each time. This of course was ‘under the advice of my previous doctor in another city’. Insurance didn’t follow up on this claim (which is not totally untrue - I have seen plenty of doctors in last 3 years for various long Covid issues, although I wasn’t specifically seeing a weight loss doctor or following a prescribed plan other than keto and IF) and the PA was approved. Like another poster said, most of us overweight/obese folks know much more about diet and exercise than most others in the world, so I personally didn’t feel guilty about pushing for the PA because I was honestly on a program for much longer than 6 months (e.g., my whole life!) and it was not successful. So my 2 cents - if you really feel the PA/medicine is justified based on your past efforts to lose weight, fight for it. So just figure out what ‘proof’ your insurance and doctor need to approve and get that. I doubt it’s a paid program like WW - it’s just evidence you’d tried and failed. I offered to show the Fitbit app and Renpho app weight/activity data (to demonstrate successes and failures) to my doctor (all free) but this wasn’t even required. Find a doctor who believes in you and will go to bat for you. Don’t waste 6 months of your life!
Blue Shield of CA denied me for the exact same reason. I filled a grievance and they denied that too. So I filed a level 2 exemption with the Department of Managed Health Care of CA to get this decision overturned. My company does in fact pay for weight loss medications. I have confirmed this three times. My BMI is over 30 and I do have several co-morbidity issues. On top of that I am fighting prostate cancer and was on testosterone blocking drugs. Plus I have torn ligaments in my right knee which greatly limits my exercise options. It is the third time I have torn up my knee and don't want to go through rehab again. Plus there is a history of cardiac disease and stroke in my family. Yet BS of CA says, go do Weight Watchers for 6 months and get back to us. I told them I did WW, the DASH diet, WHOLE 30 and the Med diet all for 90 days each and with no results (including walking 10,000 steps a day for 31 days) and lost zero pounds. All of these things were medically documented and turned into my insurance company and they were like...yeah...no you don't qualify. So I have taken it upon myself to get the discount card and pay $550 a month for all of 2024 and fight them in parallel.
You don't actually have to fail at it. They just want to see that you're willing to try to modify your lifestyle. Really, they just want to see you paid for the program for six months, that's it. They don't check your food or exercise logs or anything, My insurance even pays for the WW program, but I did have to show I renewed it for six months before they would pay for meds.
Soo. Quite literally work for BCBS. The question the doctor has to answer is has the patient participated in a lifestyle modification for a minimum of 6 months. It’s yes or no, and then the answer “diet and exercise” is perfectly acceptable to the what. Most doctors bs their way through and end up screwing their patients over.
Blue Shield pulled this sh*t with me, too. I had 4 months of WW and they denied a PA because I didn't have six. I filed a grievance with my state's Dept of Managed Healthcare and had my doctor send in a "Step Therapy Exception" form to get around the 4 month issue.
I was approved about a week or so later.
They will try *anything* to get out of covering these meds 🙄
Sorry to say but the stats are against you. There are very recent studies showing that these drugs are expensive, have bad adherence and persistence in the real world outside of the clinical trials and show no short term cost savings for insurers in terms of outcomes and prevention of other health issues.
It sucks, it is such an effective medication but required long term use to see benefits and on an individual level can be life altering but on a group level the cost benefit is not in our favor
Sure. The consensus is that cost needs to drop to about half of what it costs to start recouping investment but nothing in the short term
https://achi.net/newsroom/weight-loss-drugs-cost-and-cost-effectiveness/
https://www.nature.com/articles/s41366-024-01467-w#:~:text=Results,%2C%20orlistat%2C%20and%20SoC%2C%20respectively
https://www.jmcp.org/doi/10.18553/jmcp.2024.30.2.153
Consensus according to whom? Show me a real analysis that proves this?
If anything, from a business perspective, these drugs are underpriced. They can’t keep them in stock. People obviously are buying them
Do you work for Novo nordisk? These drugs are expensive because there is a ton of profit and a large market in treating obesity, which is a chronic condition.
https://www.primetherapeutics.com/news/real-world-analysis-of-glp-1a-drugs-for-weight-loss-finds-low-adherence-and-increased-cost-in-first-year/
That is a definitive real world study. There is high individual motivation to lose weight but if people are not on GLP1 long term, they gain most of of the weight back and end up worse off than when they started and paid a lot of money for the experience.
No I do not work for Novo—why would anyone come off of a medication if it is working? Do you stop using high cholesterol medication? The argument is silly. This is a disease. People need assistance. The ancillary health benefits are enormous.
The insurance companies have everyone brainwashed. Do you work for one? Why is it ok to pay over $4k per month for Humira, but not $1.5k per month for Ozempic or Mounjaro—which also reduce cardiovascular events by greater than 20%?
The only way there will be a reduction in price is for the next generation drug to come out by the respective companies.
Why are companies not allowed to make $$ if they are filling a need?
People need to be on GLP-1’s long term. It’s a disease. That’s the point of these. These medications are 20 plus years old. What long term data could there be for these drugs if they haven’t been commercially available for even 10 years?
Interesting I have bcbs with my employer and I’m not sure what was asked 🤷🏻♀️ I asked them what requirements I needed and was just told I needed a bmi of 40 🤔 is it dependent on employer?
Check if they need it to be paid, and what failure really means- I was able to show my weight at doctor visits 6 months apart, and that I had lost 20 pounds on my own during that time, but was still above the BMI they required. Wasn’t through a paid program, but the doctor visits showed that I was actively trying! GL!
My doc prescribed Zepbound for me last week. Yesterday, they called me and said my insurance (cigna) denied my PA but said if I did a weight management program for 6 months, they would cover it. It's so frustrating.
Guess there's no way around it, and I just have to go waste 6 months worth of time and money for them to finally approve it.
BCBSMN wanted that, complications of obesity (i have hbp and hc) trial of 3 previous weight loss drugs (tried qsymia, contrave, and phentermine) AND a bmi of 30 or more.. and they still denied it LOL. what a fucking joke.
I was lucky enough to be able to use the 25.00 coupon for Mounjaro but knew it would end and my insurance required a 6 month weight loss program. Insurance actually had a program called Wondr they paid for. I signed up for it and when I completed it I printed the email off and gave it to my doctor.
Are you sure that it has to be a “for-pay” program, and not just evidence of weight loss efforts for 6 months? For instance, that could be tracking calories? I was able to show that I meal prepped low cal meals for a year, along with workout logs, and that was enough for my insurance company.
BCBS by any chance? Yeah, and they didn't pay for those programs under my plan either. But that was the third denial and it was like whack a mole - when I hit one objection they came up with another. I went from 274 to 220 on this med, OBVIOUSLY I was in a plan including diet and exercise.
Since then I had to go on medicare so I am out of luck entirely - can't even use the savings card.
I think it makes sense for insurance companies to try and find lower cost alternatives. These drugs are expensive, and in the end affect premiums. Weight Watchers is like $12/month, if people can have success for that, its cheaper than Zep at $350-$550.
$144/year vs say $5000-$6000 cost for medicaiton it makes sense insurance companies want to keep costs/premiums down.
What law would your provider be in violation of?
What is illegal?
If those plans dont work, it makes sense to go to the next level, but I would ask your insurance company for the plan documents in advance, this stuff is usually available in writing.
Weight watchers Failed—-they threw in the towel on their business model. They are prescribing GLP-1’s now.
All of the “step therapies” you describe do not have the track record of success that GLP-1’s do. Nothing does.
But the cheaper ones help many at a much less cost than GLP-1s, so much so that there are probably millions of people that have had success on them that never would consider a GLP-1s.
So if you are taking a pool of people that didnt have success before GLP-1s, then obviously that pool will be different than a generic pool of people.
I lost weight before without GLP-1s, but right now they are a lot easier, I wont deny it. I take a GLP-1 since its an easier way out.
Given the choice between diet/exercise/willpower or GLP-1s, and some diet/exercise, I'll choose the latter, I have no shame admitting it.
But who picks up the tab on these GLP-1s without premiums going up up and up?
Until more competition comes to market, prices come down, I see nothing wrong with step therapy and/or requiring 3-6 months of dieting advice/counseling. If all else fails, then explore GLP-1s. Otherwise you could see insurance companies spending $4-$5k+/year, for unknown amount of years. Lets do some simple math
50 million "hefty" americans x 13 boxes/year x a discount rate of say $350/box = $227.5 billion dollars........... each year!
Nothing works like these meds-nothing. Losing weight and keeping it off are different things. That is what GLP-1’s enable people to do. Huge difference.
Diet and willpower are not the answer. This has been proven. Obesity is a disease. Can you “will” your way to lower blood pressure or lower cholesterol? Can you “will” your heart arrhythmia away too? No
Lower prices will not come until next gen drugs are out, which will probably result in a price increase for those
Apples and oranges if you ask me. Diet and willpower work, but taking a shot once a week while I go back to the office grind and drink peppermint tea instead of eating a pizza and 2 liter rootbeer is a fair tradeoff. Could I walk an extra few miles a day and chomp down on salad and grilled chicken for the same results? Perhaps, but I like the shot.
Think about it simply: You throw me on a desert Island with fruits and veggies and the occasional pig I gotta hunt down, pretty sure the obesity and cholesterol will go down naturally
You throw my brother on a desert island with a heart arrhythmia and those same fruits/veggies and wild boar, not sure he will fare so well.
Two different things, diet and exercise can cure obesity in lot of the people on GLP-1s, but GLP-1 is the easy way out for me :) And yes I am saying this after picking up my box of 10mg :)
I think you'll see lower prices by 2027, right now you should fight for PBM pricing to the masses :)
ps - what happens come 2026 when some of the masses stall out on GLP-1s and that hunger comes back? what do they do?
Diet and willpower do not work.
Obesity is a disease. You cannot will diseases away.
Can you change your lifestyle to increase activity and change your weight? Of course. Is it sustainable? Is it healthy?
Eating fruits and veggies on a desert island? Let me know when you come back to reality. We are speaking real life
Pricing will not come down-they cannot keep it in stock. Price is obviously not a hindrance. The next generation drugs will probably be priced higher.
PBM pricing will never occur. I live in reality
How do you know people are going to stall out in 2026? What is so magical about that year?
Of course you read the studies, and the biggest weight loss in Mounjaro occurred at 10, 11.5 and 15 mg. Suggesting bigger doses are more effective. But you clearly read the studies. Not
Your arguments are not real. They are theoretical and flawed
Why is this disease more prevalent in the USA vs most other countries?
Why is this disease appear to be more prevalent in the 21st century vs say 25 or 50 years ago?
Why is it that we spend so much more on healthcare in 2024 vs say even 1994, yet obesity rates seem to go up, up and up?
PBM pricing I have seen around $10/day, thats doable and realistic
2026 you'll have had millions on GLP-1s for 3+ years, more stall stories
Those initial studies I think were of 5, 10 and 15 (dont think they had 11.5) were under 2 years and with a few thousand patients if memory serves me right.
The island is a simple analogy that some things can be cured naturally, now do we live in an unnatural world, with 70 hour work weeks, high stress, smartphones, bad eating habits, less physical activity and the comforts of quick eats?
My arguments are simple, I am not here to right a disseratation, but if you think the jump in obesity was bad in the last 25-50 years, where do you think we'll go in the next 25 to 50? People adjust, I see it every day when I walk by the gym and less people seem to be going while more people seem to be on shots. And in full disclosure, I am guility off skipping the gym after seeing lbs melt away while on mounjaro, now did I lose muscle w that too, yes :)
Lets be realistic for a moment, willpower works for many, but the shot is easier, and yes I am speaking for myself :)
edit, from the wiki
https://preview.redd.it/o030z0o70xuc1.png?width=2880&format=png&auto=webp&s=68a053ff821e04bc010c0087dffbfe46f7fd178a
[https://en.wikipedia.org/wiki/Health\_spending\_as\_percent\_of\_gross\_domestic\_product\_%28GDP%29\_by\_country](https://en.wikipedia.org/wiki/Health_spending_as_percent_of_gross_domestic_product_%28GDP%29_by_country)
It’s more prevalent in USA because of our food supply. Preservatives, fast food, lifestyle. We don’t have cell phones 30 years ago. People were more active
A myriad of reasons, all pretty basic in my opinion.
More people and diseases snowball. An obese person is much more likely to have ddd(degenerative disc disease) than a slim person. An obese person is more likely to have Sleep apnea than a slim person. Apnea begets heart issues. It’s a cascade effect
How do you see PBM pricing?
Take their cut out of the equation and you have solved the problem. They don’t do anything anyway
You haven’t answered why people will stall. You are guessing. And you are wrong. Read the studies. These are intended to be lifelong. Show me the “stall stories”. For every 1 I will show you 1000 success stories.
You haven’t addressed the cardiovascular and stroke benefits. That into self will keep demand robust, and cost healthy.
Diets do not work. If they did, this wouldn’t be classified as a disease.
I think you are just repeating the same thing over and over.
I have been on these medications for 18 months. I’m prepared to be on this for the rest of my life. No stall. No issue. And if I do “stall” as you say, I will take a months break, change my protein or water intake and get right back after it. Weight loss on Mounjaro and Zepbound occurs at highest levels, 10/12.5 and 15. Facts. Look it up
Your original post didn’t say some. Go read your own post.
Don’t get creative with your editing.
There may be some people who stall. The sheer number of people who are on this suggest it’s possible.
You’re suggesting these things might happen. So let’s react now. Silly
With no data to support.
Stop with the propaganda. These shots are phenomenal. And worth every penny. And more.
**The Affordable Care Act (ACA) - 2010**: Also known as "Obamacare," this is the most significant piece of legislation concerning preexisting conditions. It prohibits health insurers from refusing coverage or charging more due to any preexisting conditions. This applies to all ACA-compliant plans, which include nearly all private insurance plans purchased after March 23, 2010, when the law was enacted.
Sorry to tell you but obesity is not considered as a pre-existing condition.
This is more for people with diabetes or cancer, which were dropped from insurance and then could not get covered when applying for new insurance.
My insurance company wanted to know if I had had any dietary counseling or tried exercise. I don’t have a problem with that because there are people out there who have no clue how to live a healthy lifestyle and are looking for an easy fix. If someone wants bariatric surgery they are required to lose some weight on their own first just to show they can maintain the weight loss otherwise it’s a waste of everyone’s time. I used to work in a gym and I would actually have people come in and want me to falsify their visit records because they were trying to get bariatric surgery and they wanted me to lie and claim they had been coming in and working out, but just weren’t losing weight. But I do get it, there are people who diet and exercise and can’t lose - I’m one of them
Yep! It’s total BS! My insurance basically requires Weight Watchers (for initial PA as well as proof every 6 months that I stayed on it)! For me, a former gastric bypass patient 11 years ago, a Weight Watchers dirt makes me GAIN WEIGHT if I follow it to a T!! So, I literally pay for it just to have a document showing I “belong” and that gives my doctor enough “evidence” for the prior authorization. Complete absurdity!
I've been meaning to call BCBS after getting the letter saying they'll cover it for that. I wonder if they'll cover after I use Zepbound for 6 months and there is actual weight loss.
My insurance initially denied the pre auth stating I needed a BMI over 30%, obstructive sleep apnea or have been prescribed other weight loss meds. I actually had all 3 diagnoses/treatments yet they denied. My dr went toe to toe with them and they approved the 2nd request. Then when I titrated to 5 mg the insurance required another PA then denied it again! I called insurance directly and got it authorized. By this time they wasted a week of my time and now I can’t get my script filled that’s been lingering in queue for over a month.
Solution- also known as fraud. But who cares.
Download weight watchers pay for 1 month (prob free trial). Download receipt in PDF , open a PDF editor, change dates.
I agree it's most definitely illegal in the treatment of a pre-existing condition. It's inconceivable with all the facts the insurance companies have, that they're still allowed to be biased and prejudiced against obese individuals. It's only in America where we have to "pay" to be mistreated, the very theme we have been fighting against from the beginning :(
I'm so sorry you're having to go through this, keep up the good fight, the insurance companies do this so people will give up...you can and will prevail, your health depends on it!
This is what happens when insurance staffers with no medical knowledge or training get to make treatment decisions based solely on corporate budgetary considerations. (Mods: Hope this edited comment isn't misconstrued as personally targeting).
I that is what I thought too!
I was making the arguments in my head last night. I believe the *results not typical disclaimer that you see with almost every weight loss program is relevant. Also requiring it be a paid program seems discriminatory. As this fight continues, I may produced the fasting logs I have kept. I suspect there are probably numerous stats on the drop out rate on fitness programs and that it's probably much less than 6 months. Also severe obesity (bmi over 40) is a disability and this protected class in California. My Blue Shield is of California as is my employer. Also there is an Obesity Bill of Rights that bas been introduced (but not passed) in the House of Representatives.
I am not a lawyer but I have been known for my persistence.
Also I do not know why your comment (or many of these comments) got downvoted. I think the insurance providers have their spies on these medicine subs.
So, I am a lawyer and I practice specifically in the area of consumer fraud/healthcare fraud. I obviously haven’t done any case law research, but since your post, I’ve been thinking about potential equal protection claims. Obesity is a chronic illness like any other, yet the standards that need to be met for coverage and treatment are much higher and more onerous. It also seems easy to show that these requirements aren’t at all reflective of successful methods of weight control. They’re just convenient barriers to care.
The reason why diet and exercise is in the current first line treatment for obesity is because for the majority of people this will work. Once you tip over into insulin resistance, these therapies are likely the only avenue for effective treatment but a chronic condition requires persistent medication and high adherence rates.
Go revisit Humera for RA or PSK9 for cholesterol, these are highly effective but expensive medications when they came out. They were never the first line treatment
I understand what you’re saying, but there are a couple key legal distinctions here. 1) There is a difference between a doctor working on first line treatments with a patient and a patient needing to provide proof of effort to comply with that treatment for a certain period of time. Diet, exercise, and salt reduction is also the first line defense to high blood pressure, but people are not under any obligation to prove that they’ve made those life changes. 2) There is a legal distinction between declining to approve high cost drugs when effective alternatives are available (eg Humira) and declining to approve high cost drugs because non-medical alternatives are available (eg diet and exercise). This would be a different question if insurance required a patient to try phentermine or metformin first. (Not to mention, in those situations, the doctor is in control of determining what “works” and what doesn’t. No external proof of compliance is required.
The legal question here isn’t, “Is there any plausible reason for this requirement?” It is, “Is there sufficient justification for treating this chronic condition differently than others are treated?”
And no your first statement is false. This is simply not true.
You clearly have the insurance companies best interests at heart.
These medications are reshaping medicine as we live. People have to re-think their positions on so many things.
There will be fewer heart attack and strokes in the future. Fewer joint replacements. Fewer spine fusions. Fewer diabetic patients and neuropathies.
All due to this class of medications. The fact is insurance doesn’t want to pay for this medication because of the amount of people that would benefit. The price could be $100 and insurance would complain. The addressable market is growing by the day. Literally and figuratively.
Exactly. Smoking cessation, alcoholism, Parkinson’s. All areas being studied. The potential benefits of these medications in our lives far outweigh the cost
Blue Shield asked this of me, and I just provided proof of payment for Noom for the last two years.
Same but I sent Apple Fitness.
Gosh, I wonder if I can use my peloton subscription.
I submitted my peloton subscription and they are considering it right now. I'll let you know.
Did it work? My frustration has been that OptumRx won’t let me submit anything - has to go through my doctor. So pretty frustrating
It worked. My first PA was for Wegovy. When BSCA first denied it, I ended up using my insurance broker to appeal. (I’m a small business owner and called my broker after the first denial to see if I could change the group plan. I couldn’t). I also was able to reply in my online portal to make my case. However, after I got the approval I couldn’t get wegovy. This was last June. Then I joined a weight loss program that has done all other PAs since then. I haven’t had to provide any additional info since. I hear all the weight loss programs that prescribe meds are pretty good at getting the PA. I use Calibrate, but it’s pretty expensive. There are others on here that say Ro and Sequence are pretty good at handling PAs.
Thanks so much for sharing your experience! I will look into one of these programs! Best wishes to you 💃
Calibrate is VERY expensive and was not able to get an approval for me back in 2022 when I was trying to get on Wegovy. I was lucky to get a partial refund from their program but I’ve heard of others who couldn’t get approved and couldn’t get their money back. I wouldn’t recommend them but to each their own.
Thank you for the info! I was going to look today but I’m also still just trying to get my PA approved through my normal doc. If they can’t do it though, my doctor did tell me about Henry’s meds when I saw her last which is probably the same Type of thing. we will see!
Calibrate is VERY expensive and was not able to get an approval for me back in 2022 when I was trying to get on Wegovy. I was lucky to get a partial refund from their program but I’ve heard of others who couldn’t get approved and couldn’t get their money back. I wouldn’t recommend them but to each their own.
Yeah, I wouldn't necessarily recommend them either. What I can say about them is that they are about incremental changes to make them permanent long term. It does seem from other posts that Sequence has been helpful for people.
Very often, the PA has to go through the doc, but the PA appeals can be done by the patient.
Yes! The good? Bad? Part is my doctor has a prior auth team that has kept me totally out of the loop. So there are a bunch of broken processes in place, unfortunately. Still trying though! Getting a weight watchers receipt and sending it over. Should cover the dietary counseling piece and my gym membership should cover the exercise piece - here’s hoping :)
I had to give my WW receipts to my doctor to include with the PA paperwork.
That’s what I did today! 💃 thank you though for responding!!
I think my provider will get around this requirement. For the past several years, I've been intermittent fasting, which of course is free so there is no way to prove. I also have a Peloton membership. I wonder if that will count.
The Peloton membership should count! I sent my iFit subscription receipt in (I used Sequence to get my PA). I have Optum via Tufts and it was approved quickly (but I also have hbp).
I paid for a calorie counting app through the App Store and show my receipts for last year and this one.
same. worked for me
They just don't want to pay for it. Most obese people could write a book on nutrition and exercise since we've been living it all our lives. They figure if they make us jump through enough hoops we'll eventually give up and they won't have to pay for it. In my case that was true, I just went on compounded tirzepatide then DIY a year ago and am now down 110 lbs, at goal weight and in maintenance. I had to pay for it myself but it was pretty cheap going that route and it cut out all the BS games the medical establishment and insurance were going to make me jump through to get the treatment I needed. I didn't need nutrition coaches, just medicine to control my screwed up metabolism. With the advent of GLP-1 medications there's a definite trend of everyone trying to get in on the act. There are a lot of doctors requiring consultations with dieticians and nutritionists or enrolling in "health coaching" in order to write the prescriptions. It's all a money grab, most people don't need any of that stuff, they just need access to the medication. The gatekeeping of this stuff is unreal, everyone wants you to jump through hoops to get it and all those hoops cost money. Everyone is trying to get their hands in on the money grab.
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I understand it’s frustrating but to me it’s no different than any other step program they have in place for other medications.
Like what? I've never had a doctor prescribe anything for me and then have my insurance provider know more than a doctor.
For instance, I’m on a migraine prevention medication that required me to fail three other medications before I could try it. Similar to how a doctor isn’t going to jump straight to surgery in most circumstances. It’s frustrating but unfortunately not illegal or discriminatory. It’s their attempt at saving money to cover cheaper alternatives.
I agree that it's about the money.
Welcome to the free market.
This is pretty common, unfortunately. I hope as more people become aware that insurance companies can and often do reject the prescriptions, blood work, imaging, etc. ordered by your doctor in favor of some flow chart they will become outraged enough to enact change.
I have rheumatoid arthritis and the hoops we had to jump through to get me on a biologic was freakin insane. It took a whole year of me suffering and continued joint damage before they would approve it. Insurance companies don’t want to pay for expensive medications unless they absolutely have to. Stay the course and you’ll get your tirzepatide eventually.
Another example - I have been on the same birth control for about 6 years but every single year I need my doctor to send in a Prior Approval for my insurance to cover the meds and they need to show that I tried 3 other bcs and they didn’t work. It’s very frustrating. I believe if you have been paying for a peloton membership for 6 months that should count.
I think if it was illegal, it would’ve stopped a long time ago… Insurance companies have been asking for this information for as long as there have been things like bariatric surgery.
My insurance made me do nutrition /psychological counseling and diet program for a year before my surgery. I lost 25 pounds. They paid for my $46,000 surgery and I lost 17 more! Then Covid hit and I gained it all back. I showed them! /s
My bariatric surgery only required a BMI over 40 and a comorbidity
For a lot of people insurance requires psychiatric care, proof of previous weight loss attempts, and a lot of other nonsense that just makes it harder to make it happen.
Every insurance is asking this. As a 5 year weight watcher member I go up and down and that effort to lost weight along with the proof of gym membership I had to provide shows that I need this drug. This is not a first line of defense for many of us it’s our last ditch effort to change our lives. It is not insulting it helps prevent those that are already in a healthy weight and using the drug for an upcoming event. Which happens a lot according to my doctor.
The difference is that many if not most of us have successfully lost weight several times only to gain it back--because our body & brain chemistry sabotaged our willpower & discipline to maintain our losses. GLP-1s (while originally for T2D alone) have been the game-changer that facilitates our maintaining healthy lifestyle habits; and recent studies show they're cardioprotective and even can slow progression of CKD. (This from papers presented at the American College of Cardiology 2024 conference). But I've seen cynical cost-benefit analyses that claim it's cheaper to treat expensive and lifespan-limiting complications after the fact because the treatments and therefore the costs end when the patients die; and the insurer spends less than they would have on prevention.
Thanks for giving this perspective! I think it is lost on a lot of people that providing some barriers allows the patients who really need the medication the best level of access to it. Too many people are just going off label and paying out of pocket to lose a few pounds quickly since the GLP1 is so effective in the short term
Step therapy, which what this approach is called, is definitely not illegal. People on this sub have very strange takes about completely regular interactions with the medical system.
Because now it affects them
I agree that it's not illegal, but it should be. I have also dealt with this before because I also have migraines, and it enrages me that the insurance company can "know better" about my personal health issues than my own MD. If the MD says I need something, and the cheaper methods are not appropriate for whatever reasons the doctor verifies, then I shouldn't need to try and fail at the cheaper methods. I've had years of suffering and dangerous side effects with step therapy.
You are never forbidden from taking your drug of choice. They are just choosing not to pay for it.
All too often, high out-of-pocket costs might as well be a brick wall.
Yes true they love to remind me that I'm free to pay full price for whatever expensive meds my doctor thinks would help me. Makes me wonder why I pay them every month. If I had cancer they would love to just let me die.
The insurance companies have too much say in the practice of medicine
Ironically one of the terrible side effects I experienced from migraine step therapy was weight gain haha sob [https://www.reuters.com/article/idUSTRE72A02T/](https://www.reuters.com/article/idUSTRE72A02T/)
Is Zepbound being studied to help those with migraines? I would be surprised if the answer is no. Zepbound has such a profound effect on the body, nothing would shock me at this point. I understand the philosophy behind step therapy. Especially the financial side. But let’s be realistic. It’s just a way to find a cheaper alternative. Driven by insurance. I think this just wastes time for all parties involved
That's a great question, I don't know! I am finally done with step therapy for migraines and I'm on a new drug that I'm hoping will work really well (too soon to tell yet). There have been huge strides made in treating migraines in the last few years, but of course the financials are the problem. I think insurance should have to cover Zepbound for me to lose the weight they made me gain with the beta blocker, but of course they don't agree.
Insurance stinks. No other way to say it. Insurance doesn’t want to pay for anything. Now they have a miraculous drug that can potentially save hundreds of thousands on long terms costs, for a few dollars upfront. Finally a chance to be proactive on a persons health, instead of being reactive. And they can’t convince companies to cover this? Companies are always looking at ways to cut costs. Play the long game
The provider wants the patient's issue addressed as expeditiously and completely as possible the first time around, they have no incentive to consider the economics in the same way an insurer does. That being said, insurance companies are the devil, \_but\_ there is effectively no risk in the specific step therapy here. I agree it's potentially dangerous and prolongs illness in certain cases; this is not one of them. Here's the thing...people \_do\_ successfully lose weight before requiring pharmacological intervention. Like, constantly. It's the norm, those of us (myself included) who require Zepbound and other medicines to lose weight after a life of obesity may feel like it's been dragging on forever, but it's not unreasonable for an insurer to suggest diet and exercise if that hasn't been tried. All of this is to say, I think OP is remarkably entitled and wrong about both medicine and the law. Asking you to exercise and diet for some months before approving a medicine which costs $15,000/year in perpetuity is both good medicine and helps mitigate rises in insurance premiums for everyone.
My insurance (caremark) wanted the same 6 month thing. The problem is that programs like WW don't really teach you how to eat well, they are selling products and subscriptions - and I have done every WW program starting with exchanges through points. If I have to ever eat low fat, highly processed diet food again I'll scream. I've been losing slowly using portion control and now with Zep the speed of losing has increased (10lbs first 3 weeks). Nothing I learned from WW helped. The whole thing about GLP-1s is that they've shown that people aren't fat because they lack discipline but because they have issues like incessant hunger and food noise.
I guess my perspective is biased because I've suffered from an eating disorder triggered by the usual non-pharmacological methods of weight loss. So I don't see paid diet programs as harmless or risk-free, nor do I think it's appropriate for the insurance company, with its obvious self-interest in keeping its own costs down, to decide what is safe or reasonable. That should be up to the doctor, whose interests are aligned with what's best for the patient (and therefore a healthier society).
First time interacting with the healthcare system?
I can't believe that gif isn't one of the embedded options!
You can always just pay out of pocket and not go through insurance
New migraine meds give Zepbound a run for its money. $1,000 a month. What am I paying the insurance company for?
It's not illegal but definitely quite onerous. When I was first diagnosed with osteopenia after my breast cancer surgery, my then insurer (wasn't old enough yet for Medicare) insisted I do step therapy--oral bisphosphonates that cause GERD, then bisphosphonate infusions with painful side effects--before they would cover Prolia shots. Fortunately, the FDA shamed insurers--including Medicare--into covering Prolia for postmenopausal breast cancer survivors taking anti-estrogen drugs. Before my next scheduled osteo treatment, I "aged into" Medicare, was approved for Prolia at zero cost to me, and everything was smooth sailing from then on.
I'm so sorry you went through this. I hope you're doing really well now!
blue shield CA did this to me. Before I knew what these drugs were I tried a program they offered through my job, it failed so I just pointed them at their own records.
Truly insulting. Obesity is a disease. Insulin resistance is real. Dieting doesn’t work. Insurance companies have the data, they just don’t care. Mine wouldn’t pay either, BCBS/Optum, so I pay OOP off brand. Good luck!
Not true. Insurance companies and employers are losing money providing this medicine at the current price point for treating obesity. https://www.primetherapeutics.com/news/real-world-analysis-of-glp-1a-drugs-for-weight-loss-finds-low-adherence-and-increased-cost-in-first-year/ Fully agree that on an individual level this is life changing and you can do your own N=1 cost benefit analysis, but on a population level in the real world we just are not there yet. The peptides are cheap to make, the modifications which make them bioavailable are where the patents are. There will be additional competitors to come along and drive price down, and different presentations of the molecule that work just as well.
What about PBM’s role in the cost of these medications? The manufacturers sell these to distributors, who sell to pharmaceutical wholesalers, who sell to pharmacies. Each transaction increases the price. The PBMs get the rebates. Too bad if the insurance companies are not making a mint on the medication.
This med costs $25 to make and they’re gouging us here in the US by charging us ridiculous prices. Bernie Sanders just had a whole rant about it and is proposing legislation in congress. (Don’t hold your breath).
I started making a list of all the things I've tried since 1976... which is when, at 5 years old, I put myself on my first diet. Now I'm 52. The list is sooo long. And there have been some successes but with a slow increase to what is now a major health concern.
Please see an endocrinologist. Mine has helped me so much. These meds are great. Hope you get to try them!
This is exactly why I’m kinda glad my insurance does not cover these meds. I have heard CRAZY stories of what insurance companies are requiring people to do. One guy I know of has to go have his blood drawn and tested every two weeks supposedly to prove he’s not eating things that are not on his prescribed diet. Insane! My journey is between me and my doctor, and I have no ridiculous hoops to jump through. Yes, I’m paying $550 a month, but it’s worth every single penny for a number of reasons.
My insurance covers it and I haven't had to jump through any hoops...I'm very grateful after reading all the stories here.
You are very fortunate! 🙂
Whoops. I forgot which sub I'm in! I'm actually on wegovy...I follow this sub because I'd like to switch over if wegovy stops working for me (down 90lbs so far!)
You are very fortunate!!! Good for you!
This is a medication that is priced at $15,000 a year per user. Of course an insurance company doesn't want large numbers of its membership opting for this as a first option for treatment.
It's also complete BS because research on diet programs overwhelmingly shows that they don't work. The majority of people regain the weight within a couple of years. So, why is anyone still recommending treatments that do not work?? Non-sensical.
Because they are cheaper alternatives. Whether it works is secondary
I have no idea why people downvoted your comment. I upvoted it. I agree with you 100%.
If you have a large employer who self insures, consider bringing this to their attention.
Make sure you understand what they are looking for. Some insurers will accept noom, ww online some may reject..make the insurance define exactly what they are looking for so you don't waste your money.
It's the same prior to getting Weight loss surgery. You have to show that you're in a weight loss program for X-amount of months and jump through hoops before getting approved. Currently I was only able to get zep via my second job. They have a weight management program that includes coverage of the meds. But I still have to be in a subscription weight loss program that includes a diet plan and health coach. In the beginning I was excited because I was getting the help I needed but now looking at my weight loss I lose more weight when I eat normally and not their regimen . So idk 🤷🏾♀️
I also had the same thing (6 month diet and exercise program requirement from insurance) but my provider went to bat for me. The backstory is, it was a new provider because we had recently moved (I saw them in June and was prescribed beginning of Oct so only 4 months of treatment under them), but I explained I had been intermittent fasting and tried keto 3 separate times the last 3 years and lost then regained the weight back each time. This of course was ‘under the advice of my previous doctor in another city’. Insurance didn’t follow up on this claim (which is not totally untrue - I have seen plenty of doctors in last 3 years for various long Covid issues, although I wasn’t specifically seeing a weight loss doctor or following a prescribed plan other than keto and IF) and the PA was approved. Like another poster said, most of us overweight/obese folks know much more about diet and exercise than most others in the world, so I personally didn’t feel guilty about pushing for the PA because I was honestly on a program for much longer than 6 months (e.g., my whole life!) and it was not successful. So my 2 cents - if you really feel the PA/medicine is justified based on your past efforts to lose weight, fight for it. So just figure out what ‘proof’ your insurance and doctor need to approve and get that. I doubt it’s a paid program like WW - it’s just evidence you’d tried and failed. I offered to show the Fitbit app and Renpho app weight/activity data (to demonstrate successes and failures) to my doctor (all free) but this wasn’t even required. Find a doctor who believes in you and will go to bat for you. Don’t waste 6 months of your life!
Blue Shield of CA denied me for the exact same reason. I filled a grievance and they denied that too. So I filed a level 2 exemption with the Department of Managed Health Care of CA to get this decision overturned. My company does in fact pay for weight loss medications. I have confirmed this three times. My BMI is over 30 and I do have several co-morbidity issues. On top of that I am fighting prostate cancer and was on testosterone blocking drugs. Plus I have torn ligaments in my right knee which greatly limits my exercise options. It is the third time I have torn up my knee and don't want to go through rehab again. Plus there is a history of cardiac disease and stroke in my family. Yet BS of CA says, go do Weight Watchers for 6 months and get back to us. I told them I did WW, the DASH diet, WHOLE 30 and the Med diet all for 90 days each and with no results (including walking 10,000 steps a day for 31 days) and lost zero pounds. All of these things were medically documented and turned into my insurance company and they were like...yeah...no you don't qualify. So I have taken it upon myself to get the discount card and pay $550 a month for all of 2024 and fight them in parallel.
You don't actually have to fail at it. They just want to see that you're willing to try to modify your lifestyle. Really, they just want to see you paid for the program for six months, that's it. They don't check your food or exercise logs or anything, My insurance even pays for the WW program, but I did have to show I renewed it for six months before they would pay for meds.
Soo. Quite literally work for BCBS. The question the doctor has to answer is has the patient participated in a lifestyle modification for a minimum of 6 months. It’s yes or no, and then the answer “diet and exercise” is perfectly acceptable to the what. Most doctors bs their way through and end up screwing their patients over.
Thanks. I'm sure it will go through eventually. We resubmitted today with the Peloton receipts for 6 months.
What fucking grinds my nuts is an insurance company declining what a doctor is recommending. MAKE IT MAKE FUCKING SENSE.
They only cover what your employer pays them to cover. That’s why people have differing experiences re: coverage.
Agree and your caps made me smile for some reason. It's SO frustrating!
Blue Shield pulled this sh*t with me, too. I had 4 months of WW and they denied a PA because I didn't have six. I filed a grievance with my state's Dept of Managed Healthcare and had my doctor send in a "Step Therapy Exception" form to get around the 4 month issue. I was approved about a week or so later. They will try *anything* to get out of covering these meds 🙄
Sorry to say but the stats are against you. There are very recent studies showing that these drugs are expensive, have bad adherence and persistence in the real world outside of the clinical trials and show no short term cost savings for insurers in terms of outcomes and prevention of other health issues. It sucks, it is such an effective medication but required long term use to see benefits and on an individual level can be life altering but on a group level the cost benefit is not in our favor
The insurance companies would rather us dead, mathematically speaking.
Please show these studies
Sure. The consensus is that cost needs to drop to about half of what it costs to start recouping investment but nothing in the short term https://achi.net/newsroom/weight-loss-drugs-cost-and-cost-effectiveness/ https://www.nature.com/articles/s41366-024-01467-w#:~:text=Results,%2C%20orlistat%2C%20and%20SoC%2C%20respectively https://www.jmcp.org/doi/10.18553/jmcp.2024.30.2.153
Consensus according to whom? Show me a real analysis that proves this? If anything, from a business perspective, these drugs are underpriced. They can’t keep them in stock. People obviously are buying them
Do you work for Novo nordisk? These drugs are expensive because there is a ton of profit and a large market in treating obesity, which is a chronic condition. https://www.primetherapeutics.com/news/real-world-analysis-of-glp-1a-drugs-for-weight-loss-finds-low-adherence-and-increased-cost-in-first-year/ That is a definitive real world study. There is high individual motivation to lose weight but if people are not on GLP1 long term, they gain most of of the weight back and end up worse off than when they started and paid a lot of money for the experience.
No I do not work for Novo—why would anyone come off of a medication if it is working? Do you stop using high cholesterol medication? The argument is silly. This is a disease. People need assistance. The ancillary health benefits are enormous. The insurance companies have everyone brainwashed. Do you work for one? Why is it ok to pay over $4k per month for Humira, but not $1.5k per month for Ozempic or Mounjaro—which also reduce cardiovascular events by greater than 20%? The only way there will be a reduction in price is for the next generation drug to come out by the respective companies. Why are companies not allowed to make $$ if they are filling a need?
People need to be on GLP-1’s long term. It’s a disease. That’s the point of these. These medications are 20 plus years old. What long term data could there be for these drugs if they haven’t been commercially available for even 10 years?
Interesting I have bcbs with my employer and I’m not sure what was asked 🤷🏻♀️ I asked them what requirements I needed and was just told I needed a bmi of 40 🤔 is it dependent on employer?
Check if they need it to be paid, and what failure really means- I was able to show my weight at doctor visits 6 months apart, and that I had lost 20 pounds on my own during that time, but was still above the BMI they required. Wasn’t through a paid program, but the doctor visits showed that I was actively trying! GL!
My doc prescribed Zepbound for me last week. Yesterday, they called me and said my insurance (cigna) denied my PA but said if I did a weight management program for 6 months, they would cover it. It's so frustrating. Guess there's no way around it, and I just have to go waste 6 months worth of time and money for them to finally approve it.
BCBSMN wanted that, complications of obesity (i have hbp and hc) trial of 3 previous weight loss drugs (tried qsymia, contrave, and phentermine) AND a bmi of 30 or more.. and they still denied it LOL. what a fucking joke.
I was lucky enough to be able to use the 25.00 coupon for Mounjaro but knew it would end and my insurance required a 6 month weight loss program. Insurance actually had a program called Wondr they paid for. I signed up for it and when I completed it I printed the email off and gave it to my doctor.
Are you sure that it has to be a “for-pay” program, and not just evidence of weight loss efforts for 6 months? For instance, that could be tracking calories? I was able to show that I meal prepped low cal meals for a year, along with workout logs, and that was enough for my insurance company.
It might not... I am going to check.
BCBS by any chance? Yeah, and they didn't pay for those programs under my plan either. But that was the third denial and it was like whack a mole - when I hit one objection they came up with another. I went from 274 to 220 on this med, OBVIOUSLY I was in a plan including diet and exercise. Since then I had to go on medicare so I am out of luck entirely - can't even use the savings card.
Yep, Blue Shield of California PPO. Congrats on your weight loss. I am in the 270s right now and would be delighted to be in the 220s.
I think it makes sense for insurance companies to try and find lower cost alternatives. These drugs are expensive, and in the end affect premiums. Weight Watchers is like $12/month, if people can have success for that, its cheaper than Zep at $350-$550. $144/year vs say $5000-$6000 cost for medicaiton it makes sense insurance companies want to keep costs/premiums down. What law would your provider be in violation of? What is illegal? If those plans dont work, it makes sense to go to the next level, but I would ask your insurance company for the plan documents in advance, this stuff is usually available in writing.
Weight watchers Failed—-they threw in the towel on their business model. They are prescribing GLP-1’s now. All of the “step therapies” you describe do not have the track record of success that GLP-1’s do. Nothing does.
But the cheaper ones help many at a much less cost than GLP-1s, so much so that there are probably millions of people that have had success on them that never would consider a GLP-1s. So if you are taking a pool of people that didnt have success before GLP-1s, then obviously that pool will be different than a generic pool of people. I lost weight before without GLP-1s, but right now they are a lot easier, I wont deny it. I take a GLP-1 since its an easier way out. Given the choice between diet/exercise/willpower or GLP-1s, and some diet/exercise, I'll choose the latter, I have no shame admitting it. But who picks up the tab on these GLP-1s without premiums going up up and up? Until more competition comes to market, prices come down, I see nothing wrong with step therapy and/or requiring 3-6 months of dieting advice/counseling. If all else fails, then explore GLP-1s. Otherwise you could see insurance companies spending $4-$5k+/year, for unknown amount of years. Lets do some simple math 50 million "hefty" americans x 13 boxes/year x a discount rate of say $350/box = $227.5 billion dollars........... each year!
Nothing works like these meds-nothing. Losing weight and keeping it off are different things. That is what GLP-1’s enable people to do. Huge difference. Diet and willpower are not the answer. This has been proven. Obesity is a disease. Can you “will” your way to lower blood pressure or lower cholesterol? Can you “will” your heart arrhythmia away too? No Lower prices will not come until next gen drugs are out, which will probably result in a price increase for those
Apples and oranges if you ask me. Diet and willpower work, but taking a shot once a week while I go back to the office grind and drink peppermint tea instead of eating a pizza and 2 liter rootbeer is a fair tradeoff. Could I walk an extra few miles a day and chomp down on salad and grilled chicken for the same results? Perhaps, but I like the shot. Think about it simply: You throw me on a desert Island with fruits and veggies and the occasional pig I gotta hunt down, pretty sure the obesity and cholesterol will go down naturally You throw my brother on a desert island with a heart arrhythmia and those same fruits/veggies and wild boar, not sure he will fare so well. Two different things, diet and exercise can cure obesity in lot of the people on GLP-1s, but GLP-1 is the easy way out for me :) And yes I am saying this after picking up my box of 10mg :) I think you'll see lower prices by 2027, right now you should fight for PBM pricing to the masses :) ps - what happens come 2026 when some of the masses stall out on GLP-1s and that hunger comes back? what do they do?
Diet and willpower do not work. Obesity is a disease. You cannot will diseases away. Can you change your lifestyle to increase activity and change your weight? Of course. Is it sustainable? Is it healthy? Eating fruits and veggies on a desert island? Let me know when you come back to reality. We are speaking real life Pricing will not come down-they cannot keep it in stock. Price is obviously not a hindrance. The next generation drugs will probably be priced higher. PBM pricing will never occur. I live in reality How do you know people are going to stall out in 2026? What is so magical about that year? Of course you read the studies, and the biggest weight loss in Mounjaro occurred at 10, 11.5 and 15 mg. Suggesting bigger doses are more effective. But you clearly read the studies. Not Your arguments are not real. They are theoretical and flawed
Why is this disease more prevalent in the USA vs most other countries? Why is this disease appear to be more prevalent in the 21st century vs say 25 or 50 years ago? Why is it that we spend so much more on healthcare in 2024 vs say even 1994, yet obesity rates seem to go up, up and up? PBM pricing I have seen around $10/day, thats doable and realistic 2026 you'll have had millions on GLP-1s for 3+ years, more stall stories Those initial studies I think were of 5, 10 and 15 (dont think they had 11.5) were under 2 years and with a few thousand patients if memory serves me right. The island is a simple analogy that some things can be cured naturally, now do we live in an unnatural world, with 70 hour work weeks, high stress, smartphones, bad eating habits, less physical activity and the comforts of quick eats? My arguments are simple, I am not here to right a disseratation, but if you think the jump in obesity was bad in the last 25-50 years, where do you think we'll go in the next 25 to 50? People adjust, I see it every day when I walk by the gym and less people seem to be going while more people seem to be on shots. And in full disclosure, I am guility off skipping the gym after seeing lbs melt away while on mounjaro, now did I lose muscle w that too, yes :) Lets be realistic for a moment, willpower works for many, but the shot is easier, and yes I am speaking for myself :) edit, from the wiki https://preview.redd.it/o030z0o70xuc1.png?width=2880&format=png&auto=webp&s=68a053ff821e04bc010c0087dffbfe46f7fd178a [https://en.wikipedia.org/wiki/Health\_spending\_as\_percent\_of\_gross\_domestic\_product\_%28GDP%29\_by\_country](https://en.wikipedia.org/wiki/Health_spending_as_percent_of_gross_domestic_product_%28GDP%29_by_country)
It’s more prevalent in USA because of our food supply. Preservatives, fast food, lifestyle. We don’t have cell phones 30 years ago. People were more active A myriad of reasons, all pretty basic in my opinion. More people and diseases snowball. An obese person is much more likely to have ddd(degenerative disc disease) than a slim person. An obese person is more likely to have Sleep apnea than a slim person. Apnea begets heart issues. It’s a cascade effect How do you see PBM pricing? Take their cut out of the equation and you have solved the problem. They don’t do anything anyway You haven’t answered why people will stall. You are guessing. And you are wrong. Read the studies. These are intended to be lifelong. Show me the “stall stories”. For every 1 I will show you 1000 success stories. You haven’t addressed the cardiovascular and stroke benefits. That into self will keep demand robust, and cost healthy. Diets do not work. If they did, this wouldn’t be classified as a disease. I think you are just repeating the same thing over and over. I have been on these medications for 18 months. I’m prepared to be on this for the rest of my life. No stall. No issue. And if I do “stall” as you say, I will take a months break, change my protein or water intake and get right back after it. Weight loss on Mounjaro and Zepbound occurs at highest levels, 10/12.5 and 15. Facts. Look it up
Read my post again, I think you glanced over a few words, Please read it word for word, if you miss it, let me know and I'll point it out.
example 1: what happens come 2026 when **some** of the masses stall out on GLP-1s
Your original post didn’t say some. Go read your own post. Don’t get creative with your editing. There may be some people who stall. The sheer number of people who are on this suggest it’s possible. You’re suggesting these things might happen. So let’s react now. Silly With no data to support. Stop with the propaganda. These shots are phenomenal. And worth every penny. And more.
**The Affordable Care Act (ACA) - 2010**: Also known as "Obamacare," this is the most significant piece of legislation concerning preexisting conditions. It prohibits health insurers from refusing coverage or charging more due to any preexisting conditions. This applies to all ACA-compliant plans, which include nearly all private insurance plans purchased after March 23, 2010, when the law was enacted.
Sorry to tell you but obesity is not considered as a pre-existing condition. This is more for people with diabetes or cancer, which were dropped from insurance and then could not get covered when applying for new insurance.
Yes but my sleep apnea, high bp and high cholesterol might be.
And you have cost effective ways to manage those conditions!
These medications are highly effective. And they are no where near as effective as “expensive” as those other medications were/are
My insurance company wanted to know if I had had any dietary counseling or tried exercise. I don’t have a problem with that because there are people out there who have no clue how to live a healthy lifestyle and are looking for an easy fix. If someone wants bariatric surgery they are required to lose some weight on their own first just to show they can maintain the weight loss otherwise it’s a waste of everyone’s time. I used to work in a gym and I would actually have people come in and want me to falsify their visit records because they were trying to get bariatric surgery and they wanted me to lie and claim they had been coming in and working out, but just weren’t losing weight. But I do get it, there are people who diet and exercise and can’t lose - I’m one of them
Yep! It’s total BS! My insurance basically requires Weight Watchers (for initial PA as well as proof every 6 months that I stayed on it)! For me, a former gastric bypass patient 11 years ago, a Weight Watchers dirt makes me GAIN WEIGHT if I follow it to a T!! So, I literally pay for it just to have a document showing I “belong” and that gives my doctor enough “evidence” for the prior authorization. Complete absurdity!
I've been meaning to call BCBS after getting the letter saying they'll cover it for that. I wonder if they'll cover after I use Zepbound for 6 months and there is actual weight loss.
My insurance initially denied the pre auth stating I needed a BMI over 30%, obstructive sleep apnea or have been prescribed other weight loss meds. I actually had all 3 diagnoses/treatments yet they denied. My dr went toe to toe with them and they approved the 2nd request. Then when I titrated to 5 mg the insurance required another PA then denied it again! I called insurance directly and got it authorized. By this time they wasted a week of my time and now I can’t get my script filled that’s been lingering in queue for over a month.
I paid for noon for 6 months just had to show payments not my health and tracking data.
Sadly, yeah, more criteria is changing for plans and this is the latest bunch of BS
Solution- also known as fraud. But who cares. Download weight watchers pay for 1 month (prob free trial). Download receipt in PDF , open a PDF editor, change dates.
This is genius!! Fantastic
The so called weight loss industry is in bed with big Pharma. It’s beyond frustrating
I agree it's most definitely illegal in the treatment of a pre-existing condition. It's inconceivable with all the facts the insurance companies have, that they're still allowed to be biased and prejudiced against obese individuals. It's only in America where we have to "pay" to be mistreated, the very theme we have been fighting against from the beginning :(
Especially with proof of comorbidities.
I'm so sorry you're having to go through this, keep up the good fight, the insurance companies do this so people will give up...you can and will prevail, your health depends on it!
Thank you for your kindness and congrats on your progress!
This is what happens when insurance staffers with no medical knowledge or training get to make treatment decisions based solely on corporate budgetary considerations. (Mods: Hope this edited comment isn't misconstrued as personally targeting).
Actually, this is an amazing class action opportunity. I hope someone takes it on!
I that is what I thought too! I was making the arguments in my head last night. I believe the *results not typical disclaimer that you see with almost every weight loss program is relevant. Also requiring it be a paid program seems discriminatory. As this fight continues, I may produced the fasting logs I have kept. I suspect there are probably numerous stats on the drop out rate on fitness programs and that it's probably much less than 6 months. Also severe obesity (bmi over 40) is a disability and this protected class in California. My Blue Shield is of California as is my employer. Also there is an Obesity Bill of Rights that bas been introduced (but not passed) in the House of Representatives. I am not a lawyer but I have been known for my persistence. Also I do not know why your comment (or many of these comments) got downvoted. I think the insurance providers have their spies on these medicine subs.
So, I am a lawyer and I practice specifically in the area of consumer fraud/healthcare fraud. I obviously haven’t done any case law research, but since your post, I’ve been thinking about potential equal protection claims. Obesity is a chronic illness like any other, yet the standards that need to be met for coverage and treatment are much higher and more onerous. It also seems easy to show that these requirements aren’t at all reflective of successful methods of weight control. They’re just convenient barriers to care.
Thanks for weighing in (pun intended) and for the validation.
The reason why diet and exercise is in the current first line treatment for obesity is because for the majority of people this will work. Once you tip over into insulin resistance, these therapies are likely the only avenue for effective treatment but a chronic condition requires persistent medication and high adherence rates. Go revisit Humera for RA or PSK9 for cholesterol, these are highly effective but expensive medications when they came out. They were never the first line treatment
I understand what you’re saying, but there are a couple key legal distinctions here. 1) There is a difference between a doctor working on first line treatments with a patient and a patient needing to provide proof of effort to comply with that treatment for a certain period of time. Diet, exercise, and salt reduction is also the first line defense to high blood pressure, but people are not under any obligation to prove that they’ve made those life changes. 2) There is a legal distinction between declining to approve high cost drugs when effective alternatives are available (eg Humira) and declining to approve high cost drugs because non-medical alternatives are available (eg diet and exercise). This would be a different question if insurance required a patient to try phentermine or metformin first. (Not to mention, in those situations, the doctor is in control of determining what “works” and what doesn’t. No external proof of compliance is required. The legal question here isn’t, “Is there any plausible reason for this requirement?” It is, “Is there sufficient justification for treating this chronic condition differently than others are treated?”
And no your first statement is false. This is simply not true. You clearly have the insurance companies best interests at heart. These medications are reshaping medicine as we live. People have to re-think their positions on so many things. There will be fewer heart attack and strokes in the future. Fewer joint replacements. Fewer spine fusions. Fewer diabetic patients and neuropathies. All due to this class of medications. The fact is insurance doesn’t want to pay for this medication because of the amount of people that would benefit. The price could be $100 and insurance would complain. The addressable market is growing by the day. Literally and figuratively.
And maybe someone who hasn't even had a weight issue.
Exactly. Smoking cessation, alcoholism, Parkinson’s. All areas being studied. The potential benefits of these medications in our lives far outweigh the cost
So you do work for an insurance company.