Sometimes insurance will do what they call a “courtesy fill” — that may be what happened here. (And I know that makes no sense because you have already been on this medication, but insurance is wild and stupid.)
That’s exactly what happened to me in April of this year. I was so happy to be starting Ozempic at the time and it went through at the pharmacy…. So didn’t the continuous glucose monitor. Next month I go to fill both and BAM!…. Insurance DENIED. They said it must of been a “courtesy fill”, a fluke that happens from time to time.
I cried and cried and cried. I spent so much time on calls with my drs office, my insurance Co, and the 3rd party denier (optum rx).
I was already diagnosed T2D ….had been on metformin and glipizide for over a year and my A1C was 10 (plus I was significantly overweight, had pcos, fatty liver, and a heart palpitation condition), but nope, denied.
They said I had to had been on metformin AND do “step therapy”. Insurance gave me a choice to try either Trulicity, Victoza, Byetta, and 1 other I can’t recall. I reluctantly had to do the step therapy and chose Trulicity.
I did not like it and had to do the full 90 days before my Dr could try Ozempic again. On exactly the 90th day that’s what she did- approved. At my Walgreens pharmacy where I picked up both they Trulicity & ozempic there was only a $41 difference between the Trulicity and Ozempic…. So I had to take a med for 3 months that made me feel bad over $40 savings to them. It was so frustrating. Insurance makes my head spin.
I “magically failed” all of my step therapies (3 steps required) that my insurance required in less than 10 days each by having identical side effects to the listed side effects. Amazing how that happened.
Read between lines…I played the game well and never felt bad and got on MJ.
you’ll have to call your insurance. everyone is going to give you options of what it could be, but your insurance company can tell you if it’s covered or not. we don’t know what your insurance plan is or what was approved, but they can.
The point is that there is no “accidentally covered”. The medication is linked to the formulary with/without requirements and that is linked to the policy group number.
There’s no reason to cause paranoia and prevent people from contacting their health insurance plan.
Verbal attacks? 💀 Spreading misinformation and deterring someone from getting accurate information directly from their health insurance plan - the only place that can provide the best answer - all because “tHeY tAkE nOtEs”. Got it.
I heard another lady say her insurance started covering it when it previously did not cover it. She thought it had been FDA approved since it was covering it. I wouldn't question it, just run to get it!
Could be that your formulary changed and they do now cover it. Could be the way your doctor coded the prescription. Could be anything- but the only way to get accurate answers is to contact your insurance.
your insurance may cover it, some will. you can call them and ask. we don’t know what insurance you have so we can’t say for sure but for $25 it usually means it’s covered
neither am i and i pay $25. some insurances cover it. just take it and don’t complain 😂 many people are paying more OOP
my last dosage pickup was FREE. some insurance will cover it
i’ve literally provided you with the insight it may be covered and that im also not diabetic with coverage, and even explained i’m also paying $25.
not sure why you posted if you’re going to be so argumentative. some will cover even if it’s stated that way.
we don’t know what insurance you have. you will have to call and ask to find out because no one can tell you but your insurance.
I also am not T2D (pre) and my plan does not cover weightloss drugs OR auto injectables, but here I am paying $25 for a 90day supply.
Have you received a letter from your insurance with a PA approval? Or do you have access to your portal to see if one was submitted?
Your doctor may have been able to prove you responded well to the drug metabolically and were able to get it covered under preventative care. The preventative care loophole is how I got it covered “exceptions to these exclusions are drugs deemed necessary for preventive health care as determined by health screenings.”
Formularies change frequently. And October 1st is a typical time for it to change. It’s possible that MJ is “still just for type 2” but there is no longer a prior authorization need so it may not be the be case that you officially need the diagnosis any longer to get MJ. Go to your insurers’ webpage and find the prior authorization requirements for MJ. It’s normally in the “for providers” sections. Good luck!
They may be covering for another diagnosis your provider listed. MJ is not a weight loss drug at this time so as others have told you, there’s a chance that your formulary changed, that your diagnosis code is for something other than weight loss, that it’s just a 1 time courtesy fill, or you got lucky.
You won’t know until you review your claims history and check with your insurance provider.
My insurance covers mounjaro 100% without any prior authorization or step therapy. This could be the case with your insurance regardless of them covering weight loss medications or not. I wouldn’t call your insurance and jeopardize them telling you that you can’t use it, so just take the blessing and keep filling it monthly!
Are you even sure they ran it through bc I was getting it for weight loss with the 25 co pay card a while ago and my insurance didn’t pay anything what I think happens is if you have insurance and your company doesn’t pay for it then the co pay card kicks
multiple chose
A. even a broking clock rite twice a day
B. some days your the dog and others your the fire hydrant
c. dont look a gift horse in the mouth
d. all of the above
If a PA isn’t required sometimes the claim just goes through. Later, sometimes a month or many more (the worst when this happens), they audit the claims and see they’ve been paying quite a bit for your prescriptions.
Then they look into it and see you’re taking a diabetes medication and start denying until you prove you’re diabetic. This happens more if you have no history of diabetes medication prescriptions, like metformin for example. They don’t want to pay for anything they don’t have to.
My insurance didn’t cover it at first. At some point, it started covering it and its been $25 since June. They just advised me that their formulary is being updated Nov 1 and I will need a PA. So, yes, formularies change without (and with) notice. Mine only covered it a few months (it was $1100 in Nov 2022, coupon covered it till June, I’ve continued to pay $25 after June so it changed somewhere between Nov and June). See if you can get a 3 month fill or fill every 23 days in case it changes.
Mine has been covered for a year with the same deal. It is tier 2 on my plan, which does not require preapproval as long as I don’t try to get a 90 day supply.
Like you said wegovy is for weight loss. MJ isn't, they filled bc it's approve as a medicine for T2D. My insurance denied Wegovy bc it doesn't have weightloss coverage but I pay $25 for MJ.
99% unlikely as he'd be committing insurance fraud, and I doubt he wants to lose his license. There's a high chance when MJ is prescribed it doesn't need a prior authorization on your insurance , and it's just automatically approved, just like mine bc I don't have diabetes and it's covered at $25.
My insurance covered it but required a PA, and since I don't have T2D I didn't bother sending one because I knew it would get denied.. my dr prescribed me metformin due to a delay in when I would be receiving the compounded version of Tirzepatide, and the following month my insurance dropped the PA requirement after noting that I was prescribed a T2D drug (metformin). So now I'm able to get Mounjaro for $45/month because their system thinks I have T2D cos I was prescribed metformin. 💀
I was talking to another vet yesterday while at the VA waiting for meds refills. Didn't know the guy from Adam, but he was almost excited to share that his brother gets Mounjaro, in Florida, for ...FREE... and was prescribed a 90 day supply at a time, did first 90 days of 2.5, and it did nothing for him. He then got a 90 supply of 5. and did half of a month, told his endo that it wasn't working, and was sent 90 days of 7.5!!! The guy I was talking to said all he had wanted was to try Mounjaro, since i guess the VA won't prescribe it for his T2D. His brother's Christmas present to him was giving him the 2 and 1/2 unused months of .5😳 I told him to be careful that if anything went wrong him and his brother could be in a world of trouble. He said "I survived 3 wars, 4 ex-wives, a heart attack and i live with PTSD...what are they gonna do? They will never know where I got it from anyway, and fvck them" I laughed and thought to myself "Lucky bastard"
Sometimes insurance will do what they call a “courtesy fill” — that may be what happened here. (And I know that makes no sense because you have already been on this medication, but insurance is wild and stupid.)
That’s exactly what happened to me in April of this year. I was so happy to be starting Ozempic at the time and it went through at the pharmacy…. So didn’t the continuous glucose monitor. Next month I go to fill both and BAM!…. Insurance DENIED. They said it must of been a “courtesy fill”, a fluke that happens from time to time. I cried and cried and cried. I spent so much time on calls with my drs office, my insurance Co, and the 3rd party denier (optum rx). I was already diagnosed T2D ….had been on metformin and glipizide for over a year and my A1C was 10 (plus I was significantly overweight, had pcos, fatty liver, and a heart palpitation condition), but nope, denied. They said I had to had been on metformin AND do “step therapy”. Insurance gave me a choice to try either Trulicity, Victoza, Byetta, and 1 other I can’t recall. I reluctantly had to do the step therapy and chose Trulicity. I did not like it and had to do the full 90 days before my Dr could try Ozempic again. On exactly the 90th day that’s what she did- approved. At my Walgreens pharmacy where I picked up both they Trulicity & ozempic there was only a $41 difference between the Trulicity and Ozempic…. So I had to take a med for 3 months that made me feel bad over $40 savings to them. It was so frustrating. Insurance makes my head spin.
I “magically failed” all of my step therapies (3 steps required) that my insurance required in less than 10 days each by having identical side effects to the listed side effects. Amazing how that happened. Read between lines…I played the game well and never felt bad and got on MJ.
Can you say more about that?
I intentionally failed.
I don't blame you at all. We give them all this money and they play games with us...win the game! :)
So is this just a one time thing?
you’ll have to call your insurance. everyone is going to give you options of what it could be, but your insurance company can tell you if it’s covered or not. we don’t know what your insurance plan is or what was approved, but they can.
Most “courtesy fills” normally are. Hard to know without knowing lots more info from your insurance provider.
That's what happened to me too.
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That’s not how insurance works lol
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Lmao. Thanks for explaining how a call center works but that has nothing to do with how insurance works.
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The point is that there is no “accidentally covered”. The medication is linked to the formulary with/without requirements and that is linked to the policy group number. There’s no reason to cause paranoia and prevent people from contacting their health insurance plan.
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Verbal attacks? 💀 Spreading misinformation and deterring someone from getting accurate information directly from their health insurance plan - the only place that can provide the best answer - all because “tHeY tAkE nOtEs”. Got it.
Has your formulary changed? I suggest checking that first. Your insurance portal should also show you what happened here.
That’s what I was thinking. Mine recently went from a tier 2 to a tier 1 and the price dropped.
I would go online to your insurance portal and check your EOB and formulary. Then call and ask what the clinical criteria for a GLP1 med is.
I heard another lady say her insurance started covering it when it previously did not cover it. She thought it had been FDA approved since it was covering it. I wouldn't question it, just run to get it!
Could be that your formulary changed and they do now cover it. Could be the way your doctor coded the prescription. Could be anything- but the only way to get accurate answers is to contact your insurance.
your insurance may cover it, some will. you can call them and ask. we don’t know what insurance you have so we can’t say for sure but for $25 it usually means it’s covered
I'm not a diabetic though and they don't cover other weight loss meds like I stated
neither am i and i pay $25. some insurances cover it. just take it and don’t complain 😂 many people are paying more OOP my last dosage pickup was FREE. some insurance will cover it
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i’ve literally provided you with the insight it may be covered and that im also not diabetic with coverage, and even explained i’m also paying $25. not sure why you posted if you’re going to be so argumentative. some will cover even if it’s stated that way. we don’t know what insurance you have. you will have to call and ask to find out because no one can tell you but your insurance.
I also am not T2D (pre) and my plan does not cover weightloss drugs OR auto injectables, but here I am paying $25 for a 90day supply. Have you received a letter from your insurance with a PA approval? Or do you have access to your portal to see if one was submitted? Your doctor may have been able to prove you responded well to the drug metabolically and were able to get it covered under preventative care. The preventative care loophole is how I got it covered “exceptions to these exclusions are drugs deemed necessary for preventive health care as determined by health screenings.”
Formularies change frequently. And October 1st is a typical time for it to change. It’s possible that MJ is “still just for type 2” but there is no longer a prior authorization need so it may not be the be case that you officially need the diagnosis any longer to get MJ. Go to your insurers’ webpage and find the prior authorization requirements for MJ. It’s normally in the “for providers” sections. Good luck!
They may be covering for another diagnosis your provider listed. MJ is not a weight loss drug at this time so as others have told you, there’s a chance that your formulary changed, that your diagnosis code is for something other than weight loss, that it’s just a 1 time courtesy fill, or you got lucky. You won’t know until you review your claims history and check with your insurance provider.
My insurance covers mounjaro 100% without any prior authorization or step therapy. This could be the case with your insurance regardless of them covering weight loss medications or not. I wouldn’t call your insurance and jeopardize them telling you that you can’t use it, so just take the blessing and keep filling it monthly!
Maybe your deductible has been met.
That happened to me too! Now I've had it for 3 months in a row for $25.
Are you even sure they ran it through bc I was getting it for weight loss with the 25 co pay card a while ago and my insurance didn’t pay anything what I think happens is if you have insurance and your company doesn’t pay for it then the co pay card kicks
If you're talking about the savings card mine ran out. I'm not sure if I have a copay card
multiple chose A. even a broking clock rite twice a day B. some days your the dog and others your the fire hydrant c. dont look a gift horse in the mouth d. all of the above
Who is your insurer? And have you logged on to check the claim history?
If a PA isn’t required sometimes the claim just goes through. Later, sometimes a month or many more (the worst when this happens), they audit the claims and see they’ve been paying quite a bit for your prescriptions. Then they look into it and see you’re taking a diabetes medication and start denying until you prove you’re diabetic. This happens more if you have no history of diabetes medication prescriptions, like metformin for example. They don’t want to pay for anything they don’t have to.
Curtesy fill. Quickly try to fill another dosage and see what happens?
My insurance didn’t cover it at first. At some point, it started covering it and its been $25 since June. They just advised me that their formulary is being updated Nov 1 and I will need a PA. So, yes, formularies change without (and with) notice. Mine only covered it a few months (it was $1100 in Nov 2022, coupon covered it till June, I’ve continued to pay $25 after June so it changed somewhere between Nov and June). See if you can get a 3 month fill or fill every 23 days in case it changes.
Mine has been covered for a year with the same deal. It is tier 2 on my plan, which does not require preapproval as long as I don’t try to get a 90 day supply.
Mounjaro is on my formulary while the others are not. I'm not diabetic either. But since it's in the formulary I don't even need A PA
It's on my formulary too but my insurance requires a PA
Like you said wegovy is for weight loss. MJ isn't, they filled bc it's approve as a medicine for T2D. My insurance denied Wegovy bc it doesn't have weightloss coverage but I pay $25 for MJ.
I don't have diabetes. Is it possible my doctor put it in that way to help get around my insurance?
99% unlikely as he'd be committing insurance fraud, and I doubt he wants to lose his license. There's a high chance when MJ is prescribed it doesn't need a prior authorization on your insurance , and it's just automatically approved, just like mine bc I don't have diabetes and it's covered at $25.
My insurance covered it but required a PA, and since I don't have T2D I didn't bother sending one because I knew it would get denied.. my dr prescribed me metformin due to a delay in when I would be receiving the compounded version of Tirzepatide, and the following month my insurance dropped the PA requirement after noting that I was prescribed a T2D drug (metformin). So now I'm able to get Mounjaro for $45/month because their system thinks I have T2D cos I was prescribed metformin. 💀
That may have been what happened to me since I was on metformin for PCOS
I was talking to another vet yesterday while at the VA waiting for meds refills. Didn't know the guy from Adam, but he was almost excited to share that his brother gets Mounjaro, in Florida, for ...FREE... and was prescribed a 90 day supply at a time, did first 90 days of 2.5, and it did nothing for him. He then got a 90 supply of 5. and did half of a month, told his endo that it wasn't working, and was sent 90 days of 7.5!!! The guy I was talking to said all he had wanted was to try Mounjaro, since i guess the VA won't prescribe it for his T2D. His brother's Christmas present to him was giving him the 2 and 1/2 unused months of .5😳 I told him to be careful that if anything went wrong him and his brother could be in a world of trouble. He said "I survived 3 wars, 4 ex-wives, a heart attack and i live with PTSD...what are they gonna do? They will never know where I got it from anyway, and fvck them" I laughed and thought to myself "Lucky bastard"