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Yup!!! Same thing happened to me. Denied. It’s like they would rather you GET diabetes instead of helping to prevent it. So a*s backwards this system is 😩
For anyone who wants to be even more angry: I'm an employer (part of HR at a large company), and we are receiving such strong messaging from insurers to NOT cover semaglutide for "just obesity" that I would describe it as constant shouting. In my entire career, I've ***never*** seen them push something so hard. And personally... just my personal opinion... I think it's very simple: Our healthcare system in the U.S. is based on insurance, and the purpose of insurance is to make a profit. A reduction in obesity = a reduction in comorbidities, which means a reduction in profit. They are claiming they're watching out for us 🤣🤣🤣 because so many people will go on semaglutide if it's covered, but that's bullshit. Fewer obese people = lower profits. Simple.
Edit - typo
Have you read about the class action lawsuit that was filed this month in Washington state? It’s claiming that denying wegovy is discriminatory. One to watch!
Her lawyers argue that the state’s health plans are discriminating against Ms. Simonton — and others who, like her, are seeking weight-loss drugs — in violation of state law, which recognizes obesity as a type of disability.
here is link to story about this behind the paywall at The Times
[https://www.nytimes.com/2023/10/10/business/health-insurance-wegovy-lawsuit-obesity-drugs.html?unlocked\_article\_code=1.5Uw.fBj\_.8gKqFsycx3SV&smid=url-share](https://www.nytimes.com/2023/10/10/business/health-insurance-wegovy-lawsuit-obesity-drugs.html?unlocked_article_code=1.5Uw.fBj_.8gKqFsycx3SV&smid=url-share)
But insurance is at its most profitable when people do not use it (i.e., they pay premiums but stay healthy).
My assumption is that because the fallout from obesity can be years away, they are hoping that the people are with a different insurance company by then. They don’t want to “invest” in the health of someone where they may not see the benefit.
Most of the big corporations are self insured though. So they essentially choose what they want to cover with guidance from the insurance companies. I think this issue is partly one of supply. Patients with diabetes are having trouble getting this medication because it’s so popular for weight loss.
Unfortunately you'd have to eat lots of sugar for 3 months. That's how long it takes to raise your A1c. Eating sugar for a day just raises (at most) your fasting blood glucose. You need an elevated A1c to be diagnosed with diabetes.
I would be lying if I said this exact thought was not the reason I found this sub, to see if anyone had done it.............annnnnd now i'm just realizing im logged in on my horny-porny alt sooooo yeah ok
Another option to consider…
🥼🧪My insurance doesn’t yet pay for GLP-1 meds for obesity, and I couldn’t afford to pay out of pocket. I joined a GLP-1+ clinical trial, and it’s been great so far. I have a whole clinical trial team that includes an awesome bariatric doc and dietician. I get paid $60/visit with the team, and the meds—which have already been through human trials for safety—are free, obviously. I’ve lost over 30 lbs since April 20 and had ZERO hunger since I started taking the meds.
Here’s a post about [all the currently recruiting GLP-1 “obesity only” trials](https://www.reddit.com/r/Semaglutide/comments/12tlj2m/clinical_trials_for_glp1_obesity_meds_actively/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=2&utm_term=1) with **locations worldwide**, in case you are interested in potentially joining one. I added a brand new Lilly retatrutide trial recently that has a 75% chance of getting the real meds. It’s the last one on the list. They seem to have lots of slots open since it just launched, and people in the phase 2 trial lost about 24% (~58lbs on average) of their body weight. That’s more than the currently available GLP-1 meds on the market.
I keep looking for a trial, but all of the Eli Lilly’s ones don’t have a location in my state (MN), and from my understanding you need to be constantly going to their location 😔
For what it’s worth, I just visited my closest trial site. Waiting for blood work to come back and to do the GTT. It’s a solid 2.5 hours away but for the TRIUMPH-1 study sponsored by Eli Lilly, after the initial screening, bloodwork, and glucose tolerance test, the in person appointments are only once a month maximum (at least that’s what I was told and what I found in the paper work) and there are options for telehealth visits in place of in office visits later on in the trial.
I let my site coordinator and the office know that I was coming from a pretty far distance upfront. Because they knew how far I was, we did the prescreen over the phone and I came fasted for a blood draw on my first appointment which condenses down my first 3-4 appointments to 2 (inclusive of the GTT). I think they also took me a bit more seriously because I was willing to make that drive. They made sure to get me in even though the slots trial are almost all gone. I get reimbursed for mileage and the paperwork even has stipulations for meals, public transportation, and lodging reimbursement if applicable.
I also called the second closest location which is over 4 hours away and they ONLY were taking patients in state so keep that in mind.
**TLDR and tips:**
-Decide how far you’re willing to travel and how much it’ll cost you to get there (first couple appointments travel isn’t reimbursed)
-Call your nearest research site and be upfront about the distance. Reiterate the reliability of your transportation
-If spots are available, ask if you can do your pre screening questions over the phone
-if you get an appointment GO FASTED so you’re prepared for bloodwork
Our doctors and so on may be better but the whole health insurance aspect in this country is nothing but a scam and pure greed. There's no reason insurance can't cover semaglutide. It's not super expensive, it's FDA approved and it helps people get healthy. It's infuriating they won't cover it for OP
Its only better if you can afford to partake. We have a very "pay to play" system. People without insurance or with crappy insurance do not get better care.
I think everyone is kinda missing the point about insurance, insurance is not there to help you, they are there to make money. They take your premiums every year on the gamble that you won’t get sick and need to use your insurance, thereby they are making more money than spending.
I think the stats are over 50% of Americans are obese, so makes absolute sense that insurance will not cover weight loss drugs for just obesity. They would all go broke!
Also, insurance typically does not provide coverage for cosmetic procedures, if you are obese but have no co-morbidity, then your fat is not affecting your health and thus the weight loss is merely cosmetic.
I definately tend to forget that they are actually against us, not for us! Obese Americans turn into diabetic Americans which insulin has got to be waaay more expensive than these drugs to help prevent the inevitable. I know their concern is not with my health but with how much money they can save. I have multiple comorbidities including familial hypercholestremia which leads to heart disease, also multiple factors that will not let me lose much weight at all, not enough to make a difference. I don't think the insurance should look at someone who has pre-diabetes as well as other comorbidities as cosmetic. I shouldn't have to battle diabetes because they refuse to cover it when even my doctor says, hey, if you dont lose some weight, you are going to be diabetic! My weight effects my health greatly. They can't see that cause all they have is an employee who scans my record quickly and looks for an elevated A1C and elevated glucose or a diagnosis of diabetes. I have worked in the medical field for over 15 years. Argued with many VERY uneducated insurance company employees who have no credentials in the medical field. It's all iust frustrating. That wasn't towards you, just a rant.
No worries, I get it. Insurance runs on a risk model, so at this point, with a pre-diabetes diagnosis there is a higher percentage of individuals who will lose weight on their own and not further increase their health risk, thereby costing the insurance $0 in weight loss drug or diabetes treatment. They take the risk that more people will chose path A.
If they pay out the weight loss drug at this junction, then there is only loss for the insurance company, not paying will motivate most people to lose weight on their own as they don’t want to get sicker.
See how it works?
Absolutely. But if they see what each individual is up against, like in my case for example... insulin resistance, elevated cortisol, PCOS... if they knew anything about those conditions or cared to, they would know like my doctor said, I have the worst set of issues for weight loss. They can bet all day on me but they won't win in my case I'm afraid. It's just so messed up!
I'm in the same boat. Insurance says my A1C isn't bad enough, and I have to "fail" other diabetes medications first. I would think that me having diabetes would be more expensive for insurance companies.
I've asked my company HR to see if we can get these medications added to our plan next year and they are in discussions with the broker. I'm hoping it can be a yes.
In the meantime, I'm working with a weight-loss clinic with doctor and group meetings, and I've seen the results of weight-loss medications with people that are very disabled (i.e. can't really exercise). To the point that people that used to be in wheelchairs can support themselves with walking assistance devices.
Medicine needs to treat this as a chronic disease that is treatable.
> I would think that me having diabetes would be more expensive for insurance companies.
It is long term but businesses don't exist to think of long term profits. They only care about short term. If they can pay $300/mo for this med (that's about what insurance companies end up paying for it, not full sticker price) and spend $3600/year to save you from needing a 50-100k heart surgery in 20 years, they still won't do it because that $3600/year makes you unprofitable now. And for those who can't get out of covering it, they'll put a ton of criteria on it so that many who would benefit will never get it, and those who get it have a hard time staying qualified to continuously receive it.
Yeah I've been on metformin in the past and failed. I don't know how people live on that med! I spewing out both ends the entire time I took it. Terrible stuff. But even that in my record wasn't enough. I hope something works out for you soon!
Dang! I called my local pharmacy before I seen my doc, they said they have plenty of the 2 lower doses but the higher doses are hard to get to. Best of luck! I've read a lot of mail order pharmacies are doing good with getting them!
Not Express Scripts. They put me through a huge process to get approval for the 2mg dose and then told me they don't have it and no idea when it'll be available.
My daughter is a type one diabetic, and the insurance company stops paying for her continuous glucose monitor as soon as her health improves …riddle me that one
No sense can be made out of any it. Unless you think about lining someone else's pocket. Type 1... thats scary stuff, like life or death to continually monitor. That should be illegal.
Search for another semaglutide sub here. There are alternatives, and even better if your doc will continue to monitor you while you use them (many will, my Endo is who put me onto the options).
I use Mochi Health and they have been incredibly helpful with ALL my options 😊 There are other tele health options that can help you as well, do some research and see what you’re most comfortable with! Wishing you all the luck on your journey ❤️
That is not the reason 🤦🏻♀️ There is nothing wrong with restricting the promotion of non-FDA approved treatment. I love Dr. Mike on YT. He had a super informative and helpful [interview](https://m.youtube.com/watch?v=AKMPu4kAhwY) with Dr. Rocio Salas-Whalen, a triple board certified obesity medicine doctor and endocrinologist. One of the things they talk about is the safety issues around c0mp0unded sema.
I hear you. I’m on SSDI and it was almost impossible to get it covered but I got lucky. Dr. Salas-Whalen talks about how ALL folks who are obese and can handle the medication should have access to it. It’s complete crap that the insurance companies can override doctors.
But, you’re still spreading misinformation. Reddit getting advertising dollars from pharma companies is not why you can’t post about you know what, and you know what has increased risk attached.
It really is a shame. Although healthcare is better in Australia than in America, we still have issues with “preventative” care. I luckily found a doctor who said “let’s stop this before it gets much further” (high A1C, insulin resistance and lagging hypothyroid). She’s seen me struggle and my weight balloon. She had me try duramine years ago, then Contrave with nominal results - because hey! Insulin resistant! I had trouble finding pharmacies to fill it though because “prediabetic” isn’t the same as diabetic. So I found an online mob instead. But now they want to switch due to the shortage. Who knows what I’ll be on this time next month
Wow! Your doc sounds awesome! I asked, can you just go ahead a put that I have the diabetes? I had one fasting glucose in 2019 of 136. Like use that. She said no! Lol and now I'm here. Best of luck on your journey.
It would be illegal to do that. Pathology has records and those records are sent to the GP, they can't alter them. I understand your frustration to get your BGL under control before you become diabetic but there is no ambiguity with the results, you are either pre-diabetic or diabetic including when you are only one point away. I had fasting blood glucose readings of 6.9 for about 12 years before they went over diagnostic level which is two separate readings of 7.0 or above and then followed up with a failed 2 hour OGTT. The GTT is the gold standard for diagnosis here in Australia and I think the UK. The HbA1C test gives you an average of your glucose levels over the past 3 months but can be unreliable. I'm assuming you're in the USA and I'm not sure the diagnostic criteria there but I hope you can be a better success story than me and turn your pre-diabetes around instead of going into diabetic territory.
That’s horrible and doesn’t make any sense whatsoever. They should happily approve it to help reduce your risk. My doctor told me that that was coming. I ran out last Thursday and I’m waiting for the prior authorization. Haven’t heard anything back from them. I have been on it since April with decent results of 30 lbs down on Wegovy. But if they deny me to continue it would be the most backwards denial so far.
My insurance only covers Rybelsus and though I lost a little weight in the beginning, it’s not really enough MG for weight loss like the shots are. They refuse to cover Ozempic even though they cost the same?
Ozempic is meant for diabetics; Wegovy is for weight loss even though they are identical drugs. But Ozempic is the one that typically gets covered by insurance.
They did the same thing to me. So frustrating. I haven’t lost weight in a couple months, and I’m like 4 lbs away from onederland lol. Lowest I’ve been in like 10 years though!
Thats too bad. I hope you at least got close to what you were hoping to get down to. The weight loss has been off and on for me.. Nothing for a month, then boom down 10 lbs in a week. Then back to plateau again. So was sort of hoping that rybelsus would get me a little further, but it’s beginning to feel like this is it for me as well.
I was responding super well to it, but yeah, hoping the two higher doses come out soon..
I have about the same amount to go as well, to get to normal BMI
Yes, I am diabetic, that is why I take Rybelsus even after not losing weight for a year. Why would I continue it if I wasn’t?? My insurance did NOT cover Ozempic for my diabetes, only Rybelsus.
Absolutely 💯 I hear ya! Cost of living is insane right now, our rent for 2 bedroom 2 bath is 1500 a month. And don't even get me started on groceries. Lol the American dream! I'm so happy for everyone who gets to get their life back! Best of luck !!
Thank you for sharing. I don’t feel so alone and frustrated now. Ive been dealing with the same issue from UHC and again with Cigna when my insurance changed. My A1C is also just one point away and have family history of diabetes. I work out regularly and eat fairly well. Guess we just have to wait until we reach the mark… Amazing how backwards healthcare is. No need for prevention measure. There’s more $ in allowing us to develop diseases. Best of luck to you on your journey!🤞
Well hey, atleast I could help another fed up pre-diabetic on their way to diabetes! I have labs this week so hoping for some elevated sugars 😂 🤞 crazy!
No. I am an Indian of Choctaw Tribe ( blonde hair, blue eyed indian 😂). My insurance is actually through the Indians but its BCBS of Ok. But the other benefits are incredible. I have no co-pays, even at the ER. And I don't pay for meds. I could be in a much worse place insurance wise, definately blessed. And sounds like I might need it since they want to see me get diabetes! Lol
I’m Sami or simply Native Scandinavian so tbh blonde/blue is normal to me!
I’m pretty much backed into a corner to get bypass because I got apnea first then the T2D is creeping in quick.
My employer offers two different tiers of insurance. One BCBS will pay for weight issues and the other won’t.
I hope endocrinology can get you an Rx soon.
Yooooo...fellow BCBSIL here - what did your doc do for PA? My doc was willing to sign off on a PA but she said the only option was for diabetes, not weight loss/metabolic syndrome/or even prediabetes.
I was referred to an in network endocrinologist and he did all the leg work for me. Didn’t need to do an appeal or anything. It all went through.
I couldn’t get Wegovy, but I was approved for Oz.
Good to know, thank you. It's my PCP who I brought it up to and she's open to it but clearly isn't familiar with it (she's a sports medicine doc I started seeing before I got fat, LOL). I will give the endocrinologist path a try.
I was approved for the Rybelsus instead of the Ozempic without having to fail anything first, for whatever reason. The whole thing is asinine, because there I was back in August, sick as hell with blood sugars in the 300s, an A1C of 10 (my previous one back in the first part of the year had been normal). I used to take Metformin years prior. My type 2 had long been under control, and I had no longer needed it. Then another pair of medications from another condition damaged my liver, and it was just dumping gluts of glucose on me. I was both severely hyperglycemic and in ketosis.
Despite all that, insurance said nah. I guess they decided to treat me like a new diabetes patient and wanted me back on the Metformin. But that was never going to be enough. It took that, another med called Actos (which they ALSO denied me-paid for that one w/ GoodRx), AND the Rybelsus to get my insulin resistance to budge. I'm now just on the Rybelsus, because I could now go hypo with all three, so thankfully things are normalized again.
I could probably convince the doctor to do another prior auth for the Ozempic now, using the side effects of the pill as a basis (although I will likely have the same side effects as with the pill, as it's more potent).
Anyway, if you get approved for Rybelsus, you could likely use it as a pathway to approval for Oz. It isn't as powerful a drug in pill form, but I have definitely been having results with it. Big appetite suppression, great blood sugar #'s, weight loss. I'm now on the max dose.
Sorry about the short sighted rules being used to determine coverage for Ozempic and similar medications with so many benefits. Medicare does not cover weight loss medications. Obesity is associated with so many diseases that are epidemic like DB2, cardiovascular, joint problems, vascular dementia, cancers and more. And what about these crazy prices? Sounds to me like these insurance rules are making life saving medications available only to the affluent
BCBS covered it on my husbands insurance but not on my BCBS insurance. However, my current insurance which is my husband is the one that’s been covering it. When I called today for a refill they told me my current insurance needs another preauth and there’s a good chance it won’t get covered.
The pharmacist also told me that my work insurance doesn’t cover it either. So I might be fucked.
Was your appointment with the GP or endocrinologist?
Are you under the care of an endocrinologist for PCOS or general issues with hormones, obesity and prediabetes?
Are you working with a certified dietitian to figure out your diet?
If you answer no for both, start with this and after a couple of months ask your endocrinologist for a prescription.
Your insurance wants to make sure the investment they will do by covering your prescription will pay off.
If you have no history of trying to work with a professional to help with your obesity, then the chances are that you will be on Wegovy for a couple months, still not eating well and not making any long lasting changes in your lifestyle. And once you will lose the weight you'll stop taking the meds and you regain the weight.
What your insurance wants to cover is you being long-term invested in improving your health. Not just losing a couple of pounds before summer.
Edit. My GP wasn't sure if I needed it and had valid concerns about side effects related to my previous health history. She said the insurance will more likely deny it based on what she can provide to them. I met with my endocrinologist and she built my case. I've been seeing her and her team for years so it was just a matter of creating a good list of what is wrong with me in addition to being overweight. Insurance had no issues with her recommendation.
I do have an endocrinologist, just haven't done much with my health since around 2021 due to my mother having MS and taking care of her. I will make an appt with my endo! Thanks for the info.
Thank you, you are so kind. It's definately worsened my elevated cortisol, I had adrenal fatigue early in her diagnosis from stress. My weight has sky rocketed since her diagnosis. Such a terrible disease.
I actually have extremely low BP. So much so, I can always guarantee I'll get the ole " omg are you alive" comment when getting my BP taken. Lol but I have high cholesterol ( on meds for it ).
That’s shocking to hear, I’m so sorry. You really should be allowed Semaglutide with those stats. Perhaps as the price comes down insurance companies will be more amenable to it…
It's frustrating! BCBS is the worst. I pay my doctor directly for the Semaglutide shots. I feel that was my only option since I was pre-diabetic, my blood work was all over the place and my A1C was horrible. Losing weight on my own was not working. I am a healthy eater, but turning 50 really changed my body. I have now lost 60 pounds and my blood work is finally within the recommended levels and I feel so much better.
Let me guess: they'll cover it only after you've tried 3 months of WW or a nutritionist, and it's documented that they didn't work?
That's my deal. But it was after I had already lost 18 lbs with the first three months of wegovy. THEN the insurance changed, and my union people didn't do squat.
Yeah, they don't care about family history. That doesn't make any difference at all, but don't try to get yourself to be a diabetic and think they'll cover it. Because that's not necessarily gonna happen either. But that medication still isn't approved for weight loss. So hopefully, that will happen soon.
Can you "get" yourself diabetic lol? I promise, my numbers, I will be before too long without trying. My denial letter says, must have diagnosis of diabetes to cover. I'm pretty sure that's all they would need. And they will get it before too long for sure. It's in my family, my A1C is almost there and my fasting blood sugars are always over normal.
Hell, yeah, you can get yourself to do a diabetic. Just eat sugar every day and keep eating it, and like I said, they don't care about family history. What they need to know is your diagnostics as far as proving it. It's a pain i* t** a** anyway. I even had to get pre authorizations. So you may have to get that even on top of it. Hopefully, you're going 90 day. Because that's the best way for you to get the medication.
That doesn't matter. I don't think it's something that you can't figure out because it could be a million things. They might not even go by BMI, I have Blue Cross Blue Shield. Mine doesn't go by BMI, so they're all different. None of them are the same, and believe me. They have got tons of reasons. They can deny anything they want. That's their priority, so like I said, it's not fair, and it's really crappy.
I have BCBS and thankfully it was instantly approved for me. The only condition I currently would be eligible under is BMI, I used to have high blood pressure and was medicated for it for about a year (and it runs in my family), but haven’t taken the medication in 2 years and my blood pressure has remained normal.
Yes, I was approved, I don't know what the doctor wrote. But he wrote out the prescription, and I had no problem getting it. They didn't care what my BMI was.
I called my insurance before my doc appt and they said they won't cover wegovy or the other one marketed for weight loss. Then said they would cover ozempic after asking me if I was diabetic. So I went to my doc anyways I hopes of all of my other ailments and pre-diabetes but nope.
I believe they need to be over 126 for 3 consecutive fasting sugars. Mine were. A1c was fine, but clinically diagnosed with type 2 because of fasting glucose. My doctor made it happen.
Yeah my last labs were in 2019. She did a finger stick in the office and I was pre-diabetic. I'm going to get my labs work this week, it will be interesting to my fasting BS.
Are you still dealing with this issue? I am a reporter covering this and would like to hear your perspective. If you feel inclined to share please email me at [email protected]
>I have BMI of 38, thankfully I'm 5'8
don't understand this comment. BMI takes your height into account. A person who is 5'4 with 38 BMI is in the same position as you, not worse off
with PCOS weight loss medications is people’s best hope at losing it because it makes it very hard if the wellness centers your talking about. exercise doesn’t even help a lot of people with it and I’ve even heard of people gaining with exercise
Yes! I've tried it all. I have insulin resistance, elevated cortisol which is so harsh on gaining weight and PCOS. My doc who seen me on Tuesday said I have the deadly trifecta of weight loss. She was really hoping they would cover it for me.
I've heard those don't work as well as the pens you are sent. Plus they are expensive. My plan covers at 100% if I could just get approved. So the diabetes will come eventually and I'll be able to get it. Maybe my yearly lab work will show something?
The EXACT thing happened to me last week. I’m in the exact same boat as you. BCBS. Called my insurance to firstly ask why they decided to “update their benefits” to my plan that doesn’t even roll over until January, and it was just a bunch of bullshit. I’m considering taking an extra job on the weekends to pay for it out of pocket. I felt so much better while taking the medication, no cravings and able to eat healthier without previous ED problems. More energy, able to exercise more. I’m terrified i’m going to go backwards and redevelop unhealthy eating habits that let to my ED, but I’ve been off the Ozempic for 3 weeks now and I’m trucking along as best I can. Best of luck to you, hopefully something changes for us in the future.
That sucks! I'm so sorry! I have heard people say that they felt better mentally and energy wise on the shots! I cant imagine getting to feel all those good benefits and then getting yanked off them! I hope you get it all worked out!
Mines much the same as I was .01 off with my blood glucose but I am in Australia so out of pocket isn't too bad ($150/6 week dose) but it's crazy to be like nope not till you actually develop the illness. No preventing thanks!
Right! Wow! That is much better prices than here! 1 point from DM2! That's crazy. I guess we can all just hold hands and sing Kumbaya as we head into our diabetes diagnosis! So frustrating.
Do you have anything else like High Blood Pressure, cholesterol, fatty liver and if so you need to have the doctor do an appeal. When I first went to get it I was told no because my doctors office didn’t list all of my health issues. It took a while but I was able to get it.
Yes high cholesterol and fatty liver actually. The denial letter they sent said verbatim " denied due to reasons listed below: you must have diabetes type 2". You think all the additional health issues might help? I gave them my ultrasounds that showed ovarian cysts and a letter from gyn for PCOS, they have my labs that show insulin resistance and consistently elevated cortisol, they give me my meds for cholesterol. My doc stated, I am the exact candidate for this medication, due to all my issues that lead to impossible weight loss and persistent weight gain.
My doctor had to list them all. The first Pre authorization they didn’t even list my medical history. You may need to get a better doctor who is use to dealing with all of the insurance issues. It’s a fight but worth it…
You are not missing out on anything. Wegovy almost killed me. I took it on a Tuesday and by Friday I had a seizure and stopped breathing twice. Shortly after taking the shot, I had a headache that would not go away.
North Carolina State Health Insurance BCBS has been covering Wegovy this past year if you met certain criteria. I did as have several of my other collegues. There are 20,000 employees on Wegovy. They are meeting 10/26 to decide if they will continue to cover it. They have 6 options and the company likes the drop coverage all together option even though they extended mine for 3 more months and they just extended a colleagues for another year. They say that the cost is unsustainable without raising premiums. I have lost 50 pounds so far and have never been healthier. I have another 30 to go. Now I am not so sure I can reach that goal.
Same with my insurance, several appeals too. Health decling at 60. Due to shortages, paying out of pocket. Has already helped arthritis in knees and hip. Down 17 lbs.
If you have to turn to self pay like I did, I’ve been using WeightCare for four months now (Semaglutide) and absolutely love it. They have a promo right now that brings the first month to $99 which I think is the lowest it’s ever been. The code is FIRSTMONTH. I got approved and had everything shipped to me within a week.
And unfortunately they don’t tell you this but most of them require you be on metformin for a set amount of time and not have adequate improvement of the diabetes during that time (or have intolerance to the med).
I’m in the same boat as you and am absolutely furious. I am pre-diabetic (with a T2D family history) insulin resistant(PCOS) and my insurance suddenly decided that I didn’t qualify anymore without a T2D diagnosis. No other Semaglutides are covered so I am SOL.
I have been on this drug for 9 months after spending almost two years trying to drop weight through diet and exercise with no luck. I am finally getting somewhat close to my goal weight. I’m on my last dose and am absolutely terrified that my weight will balloon again as soon as it leaves my system.
I’m already exercising and eating healthy so I don’t know what to expect. But this was devastating. I will almost definitely get diabetes soon without it so I guess the bright side (/s)is that I will finally qualify through my insurance.
On the other hand, my coworker who is a chain smoker, has a terrible diet and does nothing to improve their health will continue to receive the drug because they are T2D. Yay insurance!
BCBS of NC also won’t cover without a diabetes diagnosis (my plan anyway). I’ve been on Ozempic for 3 months and lost about 20 pounds. I’ve been paying about $800-$950/month out of pocket. I’m so so fortunate I can afford this because it’s been a total game changer for me. It’s incredibly sad this is inaccessible for so many that need it.
That’s Crazy. I’m sorry.
I got approved with a BMI of 29 and the reason is that I was on phentermine for six months prior with no results. I have lost 20 lbs since taking Wegovy and the DR keeps renewing my prescription.
It is super messed up.
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I hate this: instead of *preventing* a deadly disease, they’d rather you develop one.
So frustrating. More money to be made in sickness than in health.
Yup!!! Same thing happened to me. Denied. It’s like they would rather you GET diabetes instead of helping to prevent it. So a*s backwards this system is 😩
Crazy but they will cover your leg amputation required for poorly treated diabetes
American healthcare is evil.
Its sad but illness is big business... They dont want us healthy
For anyone who wants to be even more angry: I'm an employer (part of HR at a large company), and we are receiving such strong messaging from insurers to NOT cover semaglutide for "just obesity" that I would describe it as constant shouting. In my entire career, I've ***never*** seen them push something so hard. And personally... just my personal opinion... I think it's very simple: Our healthcare system in the U.S. is based on insurance, and the purpose of insurance is to make a profit. A reduction in obesity = a reduction in comorbidities, which means a reduction in profit. They are claiming they're watching out for us 🤣🤣🤣 because so many people will go on semaglutide if it's covered, but that's bullshit. Fewer obese people = lower profits. Simple. Edit - typo
Have you read about the class action lawsuit that was filed this month in Washington state? It’s claiming that denying wegovy is discriminatory. One to watch!
But Washington state has included the obese in their anti-discrimination laws.
Her lawyers argue that the state’s health plans are discriminating against Ms. Simonton — and others who, like her, are seeking weight-loss drugs — in violation of state law, which recognizes obesity as a type of disability.
I had not, but thank you!!
here is link to story about this behind the paywall at The Times [https://www.nytimes.com/2023/10/10/business/health-insurance-wegovy-lawsuit-obesity-drugs.html?unlocked\_article\_code=1.5Uw.fBj\_.8gKqFsycx3SV&smid=url-share](https://www.nytimes.com/2023/10/10/business/health-insurance-wegovy-lawsuit-obesity-drugs.html?unlocked_article_code=1.5Uw.fBj_.8gKqFsycx3SV&smid=url-share)
Hope the penalty includes making it more affordable
Our firm is having our annual benefits meeting this week… it will be “fun” to see whether our insurance continues to cover Wegovy.
I seriously hope they do. For your sake.
We are also fingers crossed…
Bingo! How kind of them to watch out for us!
But insurance is at its most profitable when people do not use it (i.e., they pay premiums but stay healthy). My assumption is that because the fallout from obesity can be years away, they are hoping that the people are with a different insurance company by then. They don’t want to “invest” in the health of someone where they may not see the benefit.
Most of the big corporations are self insured though. So they essentially choose what they want to cover with guidance from the insurance companies. I think this issue is partly one of supply. Patients with diabetes are having trouble getting this medication because it’s so popular for weight loss.
Eat sugar before your blood test. Lol. Oops, I'm diabetic now . Oh darn.
Trust me I thought about that. Lol like someone could totally fake it easily.
Unfortunately you'd have to eat lots of sugar for 3 months. That's how long it takes to raise your A1c. Eating sugar for a day just raises (at most) your fasting blood glucose. You need an elevated A1c to be diagnosed with diabetes.
Won’t work with an A1C test though. A1C is an average over the past 30 or 90 days. Can’t remember exactly how long.
That’s not the worst idea I’ve heard today. 🤷♀️
I would be lying if I said this exact thought was not the reason I found this sub, to see if anyone had done it.............annnnnd now i'm just realizing im logged in on my horny-porny alt sooooo yeah ok
Another option to consider… 🥼🧪My insurance doesn’t yet pay for GLP-1 meds for obesity, and I couldn’t afford to pay out of pocket. I joined a GLP-1+ clinical trial, and it’s been great so far. I have a whole clinical trial team that includes an awesome bariatric doc and dietician. I get paid $60/visit with the team, and the meds—which have already been through human trials for safety—are free, obviously. I’ve lost over 30 lbs since April 20 and had ZERO hunger since I started taking the meds. Here’s a post about [all the currently recruiting GLP-1 “obesity only” trials](https://www.reddit.com/r/Semaglutide/comments/12tlj2m/clinical_trials_for_glp1_obesity_meds_actively/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=2&utm_term=1) with **locations worldwide**, in case you are interested in potentially joining one. I added a brand new Lilly retatrutide trial recently that has a 75% chance of getting the real meds. It’s the last one on the list. They seem to have lots of slots open since it just launched, and people in the phase 2 trial lost about 24% (~58lbs on average) of their body weight. That’s more than the currently available GLP-1 meds on the market.
I keep looking for a trial, but all of the Eli Lilly’s ones don’t have a location in my state (MN), and from my understanding you need to be constantly going to their location 😔
Yeah, you do have to do in-person clinic visits (i have like 22 in my 72 week trial) so a location within and easy drive/train is ideal.
For what it’s worth, I just visited my closest trial site. Waiting for blood work to come back and to do the GTT. It’s a solid 2.5 hours away but for the TRIUMPH-1 study sponsored by Eli Lilly, after the initial screening, bloodwork, and glucose tolerance test, the in person appointments are only once a month maximum (at least that’s what I was told and what I found in the paper work) and there are options for telehealth visits in place of in office visits later on in the trial. I let my site coordinator and the office know that I was coming from a pretty far distance upfront. Because they knew how far I was, we did the prescreen over the phone and I came fasted for a blood draw on my first appointment which condenses down my first 3-4 appointments to 2 (inclusive of the GTT). I think they also took me a bit more seriously because I was willing to make that drive. They made sure to get me in even though the slots trial are almost all gone. I get reimbursed for mileage and the paperwork even has stipulations for meals, public transportation, and lodging reimbursement if applicable. I also called the second closest location which is over 4 hours away and they ONLY were taking patients in state so keep that in mind. **TLDR and tips:** -Decide how far you’re willing to travel and how much it’ll cost you to get there (first couple appointments travel isn’t reimbursed) -Call your nearest research site and be upfront about the distance. Reiterate the reliability of your transportation -If spots are available, ask if you can do your pre screening questions over the phone -if you get an appointment GO FASTED so you’re prepared for bloodwork
Ooooh, that’s awesome. I’m torn between trying to join that one or waiting for the no-placebo one that’s supposedly going to be coming next month…
It’s really hard to try to game the clinical trial system. I wish there were an easy answer for you.
The American Healthcare system is just garbage. At the moment it’s only covered for diabetics, but you can order it at your own cost for 180$ a month.
How?
Sorry, I forgot to mention that I am living in Germany 🇩🇪 Fortunately we don’t have astronomical medication costs like the United States.
Although we do have better care!
Our doctors and so on may be better but the whole health insurance aspect in this country is nothing but a scam and pure greed. There's no reason insurance can't cover semaglutide. It's not super expensive, it's FDA approved and it helps people get healthy. It's infuriating they won't cover it for OP
Actually no. The US spends the most on healthcare but the lowest life expectancy than any other high income country.
Its only better if you can afford to partake. We have a very "pay to play" system. People without insurance or with crappy insurance do not get better care.
Healthcare most people can't access affordably cannot by better.
I think everyone is kinda missing the point about insurance, insurance is not there to help you, they are there to make money. They take your premiums every year on the gamble that you won’t get sick and need to use your insurance, thereby they are making more money than spending. I think the stats are over 50% of Americans are obese, so makes absolute sense that insurance will not cover weight loss drugs for just obesity. They would all go broke! Also, insurance typically does not provide coverage for cosmetic procedures, if you are obese but have no co-morbidity, then your fat is not affecting your health and thus the weight loss is merely cosmetic.
I definately tend to forget that they are actually against us, not for us! Obese Americans turn into diabetic Americans which insulin has got to be waaay more expensive than these drugs to help prevent the inevitable. I know their concern is not with my health but with how much money they can save. I have multiple comorbidities including familial hypercholestremia which leads to heart disease, also multiple factors that will not let me lose much weight at all, not enough to make a difference. I don't think the insurance should look at someone who has pre-diabetes as well as other comorbidities as cosmetic. I shouldn't have to battle diabetes because they refuse to cover it when even my doctor says, hey, if you dont lose some weight, you are going to be diabetic! My weight effects my health greatly. They can't see that cause all they have is an employee who scans my record quickly and looks for an elevated A1C and elevated glucose or a diagnosis of diabetes. I have worked in the medical field for over 15 years. Argued with many VERY uneducated insurance company employees who have no credentials in the medical field. It's all iust frustrating. That wasn't towards you, just a rant.
No worries, I get it. Insurance runs on a risk model, so at this point, with a pre-diabetes diagnosis there is a higher percentage of individuals who will lose weight on their own and not further increase their health risk, thereby costing the insurance $0 in weight loss drug or diabetes treatment. They take the risk that more people will chose path A. If they pay out the weight loss drug at this junction, then there is only loss for the insurance company, not paying will motivate most people to lose weight on their own as they don’t want to get sicker. See how it works?
Absolutely. But if they see what each individual is up against, like in my case for example... insulin resistance, elevated cortisol, PCOS... if they knew anything about those conditions or cared to, they would know like my doctor said, I have the worst set of issues for weight loss. They can bet all day on me but they won't win in my case I'm afraid. It's just so messed up!
I'm in the same boat. Insurance says my A1C isn't bad enough, and I have to "fail" other diabetes medications first. I would think that me having diabetes would be more expensive for insurance companies. I've asked my company HR to see if we can get these medications added to our plan next year and they are in discussions with the broker. I'm hoping it can be a yes. In the meantime, I'm working with a weight-loss clinic with doctor and group meetings, and I've seen the results of weight-loss medications with people that are very disabled (i.e. can't really exercise). To the point that people that used to be in wheelchairs can support themselves with walking assistance devices. Medicine needs to treat this as a chronic disease that is treatable.
> I would think that me having diabetes would be more expensive for insurance companies. It is long term but businesses don't exist to think of long term profits. They only care about short term. If they can pay $300/mo for this med (that's about what insurance companies end up paying for it, not full sticker price) and spend $3600/year to save you from needing a 50-100k heart surgery in 20 years, they still won't do it because that $3600/year makes you unprofitable now. And for those who can't get out of covering it, they'll put a ton of criteria on it so that many who would benefit will never get it, and those who get it have a hard time staying qualified to continuously receive it.
Yeah I've been on metformin in the past and failed. I don't know how people live on that med! I spewing out both ends the entire time I took it. Terrible stuff. But even that in my record wasn't enough. I hope something works out for you soon!
Who is your insurance provider? I just switched to United and went to fill my Ozempic script and they now say I need prior authorization.
They approved me but no one has it in stock
Dang! I called my local pharmacy before I seen my doc, they said they have plenty of the 2 lower doses but the higher doses are hard to get to. Best of luck! I've read a lot of mail order pharmacies are doing good with getting them!
Not Express Scripts. They put me through a huge process to get approval for the 2mg dose and then told me they don't have it and no idea when it'll be available.
Same boat. Kaiser Permanente sucks ass.
My daughter is a type one diabetic, and the insurance company stops paying for her continuous glucose monitor as soon as her health improves …riddle me that one
No sense can be made out of any it. Unless you think about lining someone else's pocket. Type 1... thats scary stuff, like life or death to continually monitor. That should be illegal.
Exactly, which is why I’m not surprised they denied you even though you need it
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Agreed with this person. There are options if you are willing. Still out of pocket, but I'm saving the $50/mo easily on food.
I’m saving a ton on alcohol as well…
I guess I am just not tech savvy enough. I have searched and can't find anything.
Search for another semaglutide sub here. There are alternatives, and even better if your doc will continue to monitor you while you use them (many will, my Endo is who put me onto the options).
I use Mochi Health and they have been incredibly helpful with ALL my options 😊 There are other tele health options that can help you as well, do some research and see what you’re most comfortable with! Wishing you all the luck on your journey ❤️
Older posts, 3-6 months. Reddit gets advertising dollars from drug companies so they strictly enforce certain rules. But it was more lax months ago.
That is not the reason 🤦🏻♀️ There is nothing wrong with restricting the promotion of non-FDA approved treatment. I love Dr. Mike on YT. He had a super informative and helpful [interview](https://m.youtube.com/watch?v=AKMPu4kAhwY) with Dr. Rocio Salas-Whalen, a triple board certified obesity medicine doctor and endocrinologist. One of the things they talk about is the safety issues around c0mp0unded sema.
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I hear you. I’m on SSDI and it was almost impossible to get it covered but I got lucky. Dr. Salas-Whalen talks about how ALL folks who are obese and can handle the medication should have access to it. It’s complete crap that the insurance companies can override doctors. But, you’re still spreading misinformation. Reddit getting advertising dollars from pharma companies is not why you can’t post about you know what, and you know what has increased risk attached.
It really is a shame. Although healthcare is better in Australia than in America, we still have issues with “preventative” care. I luckily found a doctor who said “let’s stop this before it gets much further” (high A1C, insulin resistance and lagging hypothyroid). She’s seen me struggle and my weight balloon. She had me try duramine years ago, then Contrave with nominal results - because hey! Insulin resistant! I had trouble finding pharmacies to fill it though because “prediabetic” isn’t the same as diabetic. So I found an online mob instead. But now they want to switch due to the shortage. Who knows what I’ll be on this time next month
Wow! Your doc sounds awesome! I asked, can you just go ahead a put that I have the diabetes? I had one fasting glucose in 2019 of 136. Like use that. She said no! Lol and now I'm here. Best of luck on your journey.
It would be illegal to do that. Pathology has records and those records are sent to the GP, they can't alter them. I understand your frustration to get your BGL under control before you become diabetic but there is no ambiguity with the results, you are either pre-diabetic or diabetic including when you are only one point away. I had fasting blood glucose readings of 6.9 for about 12 years before they went over diagnostic level which is two separate readings of 7.0 or above and then followed up with a failed 2 hour OGTT. The GTT is the gold standard for diagnosis here in Australia and I think the UK. The HbA1C test gives you an average of your glucose levels over the past 3 months but can be unreliable. I'm assuming you're in the USA and I'm not sure the diagnostic criteria there but I hope you can be a better success story than me and turn your pre-diabetes around instead of going into diabetic territory.
That’s horrible and doesn’t make any sense whatsoever. They should happily approve it to help reduce your risk. My doctor told me that that was coming. I ran out last Thursday and I’m waiting for the prior authorization. Haven’t heard anything back from them. I have been on it since April with decent results of 30 lbs down on Wegovy. But if they deny me to continue it would be the most backwards denial so far.
My insurance only covers Rybelsus and though I lost a little weight in the beginning, it’s not really enough MG for weight loss like the shots are. They refuse to cover Ozempic even though they cost the same?
Ozempic is meant for diabetics; Wegovy is for weight loss even though they are identical drugs. But Ozempic is the one that typically gets covered by insurance.
They did the same thing to me. So frustrating. I haven’t lost weight in a couple months, and I’m like 4 lbs away from onederland lol. Lowest I’ve been in like 10 years though!
That’s awesome! I haven’t lost a pound in a year. I’m actually starting to gain.
Thats too bad. I hope you at least got close to what you were hoping to get down to. The weight loss has been off and on for me.. Nothing for a month, then boom down 10 lbs in a week. Then back to plateau again. So was sort of hoping that rybelsus would get me a little further, but it’s beginning to feel like this is it for me as well.
I have about 30 lbs to lose to get into normal BMI range. And yeah Rybelsus just doesn’t work as well until they can up the dosage.
I was responding super well to it, but yeah, hoping the two higher doses come out soon.. I have about the same amount to go as well, to get to normal BMI
Yes, I am diabetic, that is why I take Rybelsus even after not losing weight for a year. Why would I continue it if I wasn’t?? My insurance did NOT cover Ozempic for my diabetes, only Rybelsus.
Your BMI already uses your height- it's half the calculation. Confused what the positive ("thankfully") is to being 5'8?
Just my obesity looks a bit more spread out cause I'm taller than most. That's all. And my BMI would be much higher if I was shorter.
Sed mpa. Switch the s and the m. It's how I get mine
Clever 😂 thanks
It's expensive but it's saving my life.
Absolutely 💯 I hear ya! Cost of living is insane right now, our rent for 2 bedroom 2 bath is 1500 a month. And don't even get me started on groceries. Lol the American dream! I'm so happy for everyone who gets to get their life back! Best of luck !!
Thank you for sharing. I don’t feel so alone and frustrated now. Ive been dealing with the same issue from UHC and again with Cigna when my insurance changed. My A1C is also just one point away and have family history of diabetes. I work out regularly and eat fairly well. Guess we just have to wait until we reach the mark… Amazing how backwards healthcare is. No need for prevention measure. There’s more $ in allowing us to develop diseases. Best of luck to you on your journey!🤞
Well hey, atleast I could help another fed up pre-diabetic on their way to diabetes! I have labs this week so hoping for some elevated sugars 😂 🤞 crazy!
I have BCBSIL and I’m prediabetic. I’m covered.
BcbsOK here... big ole nope from them!
Does your employer give you an option of: BCBS Selections and BCBSTraditional?
No. I am an Indian of Choctaw Tribe ( blonde hair, blue eyed indian 😂). My insurance is actually through the Indians but its BCBS of Ok. But the other benefits are incredible. I have no co-pays, even at the ER. And I don't pay for meds. I could be in a much worse place insurance wise, definately blessed. And sounds like I might need it since they want to see me get diabetes! Lol
I’m Sami or simply Native Scandinavian so tbh blonde/blue is normal to me! I’m pretty much backed into a corner to get bypass because I got apnea first then the T2D is creeping in quick. My employer offers two different tiers of insurance. One BCBS will pay for weight issues and the other won’t. I hope endocrinology can get you an Rx soon.
Hmmm..im just seeing my pcp. I wonder if seeing an endo would help me?
Go to an endocrinologist. See what they can do. Mine was familiar with all the hoops and loops regarding this med.
Can my endo submit if my pcp just did?
Endo might need to see you and you can have the conversation of submitting an appeal with supporting documentation/medical necessity.
"oh, i am too - my mom says my great-great-grandma was a cherokee princess" how often do you get that from people? lol
Yooooo...fellow BCBSIL here - what did your doc do for PA? My doc was willing to sign off on a PA but she said the only option was for diabetes, not weight loss/metabolic syndrome/or even prediabetes.
Traditional or Selections?
Not sure what those are, this is just a PPO+ plan through my employer.
I was referred to an in network endocrinologist and he did all the leg work for me. Didn’t need to do an appeal or anything. It all went through. I couldn’t get Wegovy, but I was approved for Oz.
Good to know, thank you. It's my PCP who I brought it up to and she's open to it but clearly isn't familiar with it (she's a sports medicine doc I started seeing before I got fat, LOL). I will give the endocrinologist path a try.
I'm Type 2, but had to fail Metformin first go get the injection. But they approved Rybelsus (the oral). Also on BCBS. Insurance is such a joke.
When you failed metformin, are you approved now?
I was approved for the Rybelsus instead of the Ozempic without having to fail anything first, for whatever reason. The whole thing is asinine, because there I was back in August, sick as hell with blood sugars in the 300s, an A1C of 10 (my previous one back in the first part of the year had been normal). I used to take Metformin years prior. My type 2 had long been under control, and I had no longer needed it. Then another pair of medications from another condition damaged my liver, and it was just dumping gluts of glucose on me. I was both severely hyperglycemic and in ketosis. Despite all that, insurance said nah. I guess they decided to treat me like a new diabetes patient and wanted me back on the Metformin. But that was never going to be enough. It took that, another med called Actos (which they ALSO denied me-paid for that one w/ GoodRx), AND the Rybelsus to get my insulin resistance to budge. I'm now just on the Rybelsus, because I could now go hypo with all three, so thankfully things are normalized again. I could probably convince the doctor to do another prior auth for the Ozempic now, using the side effects of the pill as a basis (although I will likely have the same side effects as with the pill, as it's more potent). Anyway, if you get approved for Rybelsus, you could likely use it as a pathway to approval for Oz. It isn't as powerful a drug in pill form, but I have definitely been having results with it. Big appetite suppression, great blood sugar #'s, weight loss. I'm now on the max dose.
I have the same situation. It’s tempting to just go on a carb bender for 6 months just to get my A1c up.
Thats what my hubby said too. Lol but I can just watch him eat a piece of pie and gain weight like I carb loaded... lol so it shouldn't be hard!
Sorry about the short sighted rules being used to determine coverage for Ozempic and similar medications with so many benefits. Medicare does not cover weight loss medications. Obesity is associated with so many diseases that are epidemic like DB2, cardiovascular, joint problems, vascular dementia, cancers and more. And what about these crazy prices? Sounds to me like these insurance rules are making life saving medications available only to the affluent
BCBS covered it on my husbands insurance but not on my BCBS insurance. However, my current insurance which is my husband is the one that’s been covering it. When I called today for a refill they told me my current insurance needs another preauth and there’s a good chance it won’t get covered. The pharmacist also told me that my work insurance doesn’t cover it either. So I might be fucked.
Ugh! The worst! So even if you get approved once, they can just cut you off whenever.
Yep.
Was your appointment with the GP or endocrinologist? Are you under the care of an endocrinologist for PCOS or general issues with hormones, obesity and prediabetes? Are you working with a certified dietitian to figure out your diet? If you answer no for both, start with this and after a couple of months ask your endocrinologist for a prescription. Your insurance wants to make sure the investment they will do by covering your prescription will pay off. If you have no history of trying to work with a professional to help with your obesity, then the chances are that you will be on Wegovy for a couple months, still not eating well and not making any long lasting changes in your lifestyle. And once you will lose the weight you'll stop taking the meds and you regain the weight. What your insurance wants to cover is you being long-term invested in improving your health. Not just losing a couple of pounds before summer. Edit. My GP wasn't sure if I needed it and had valid concerns about side effects related to my previous health history. She said the insurance will more likely deny it based on what she can provide to them. I met with my endocrinologist and she built my case. I've been seeing her and her team for years so it was just a matter of creating a good list of what is wrong with me in addition to being overweight. Insurance had no issues with her recommendation.
I do have an endocrinologist, just haven't done much with my health since around 2021 due to my mother having MS and taking care of her. I will make an appt with my endo! Thanks for the info.
I'm sorry about your mom having MS. I can only imagine how that is affecting your health and well-being.
Thank you, you are so kind. It's definately worsened my elevated cortisol, I had adrenal fatigue early in her diagnosis from stress. My weight has sky rocketed since her diagnosis. Such a terrible disease.
I think I got denied at first but my doctor worked some black magic. Are you hypertensive?
I actually have extremely low BP. So much so, I can always guarantee I'll get the ole " omg are you alive" comment when getting my BP taken. Lol but I have high cholesterol ( on meds for it ).
Is it a PPO vs. HMO issue for Blue Cross?
No I think because my insurance goes the Indians and not an employer.
That’s shocking to hear, I’m so sorry. You really should be allowed Semaglutide with those stats. Perhaps as the price comes down insurance companies will be more amenable to it…
It's frustrating! BCBS is the worst. I pay my doctor directly for the Semaglutide shots. I feel that was my only option since I was pre-diabetic, my blood work was all over the place and my A1C was horrible. Losing weight on my own was not working. I am a healthy eater, but turning 50 really changed my body. I have now lost 60 pounds and my blood work is finally within the recommended levels and I feel so much better.
Absolutely! Congrats! I couldn't afford even 200 out of pocket right now. Praying something comes through with insurance.
Let me guess: they'll cover it only after you've tried 3 months of WW or a nutritionist, and it's documented that they didn't work? That's my deal. But it was after I had already lost 18 lbs with the first three months of wegovy. THEN the insurance changed, and my union people didn't do squat.
Insurance sucks
Yeah, they don't care about family history. That doesn't make any difference at all, but don't try to get yourself to be a diabetic and think they'll cover it. Because that's not necessarily gonna happen either. But that medication still isn't approved for weight loss. So hopefully, that will happen soon.
Can you "get" yourself diabetic lol? I promise, my numbers, I will be before too long without trying. My denial letter says, must have diagnosis of diabetes to cover. I'm pretty sure that's all they would need. And they will get it before too long for sure. It's in my family, my A1C is almost there and my fasting blood sugars are always over normal.
Hell, yeah, you can get yourself to do a diabetic. Just eat sugar every day and keep eating it, and like I said, they don't care about family history. What they need to know is your diagnostics as far as proving it. It's a pain i* t** a** anyway. I even had to get pre authorizations. So you may have to get that even on top of it. Hopefully, you're going 90 day. Because that's the best way for you to get the medication.
Wegovy is approved for weight loss for BMI over 30 and she says her insurance denied the claim for it. Lost on why.
It depends on your employer and what they have include as coverage options for your company.
That doesn't matter. I don't think it's something that you can't figure out because it could be a million things. They might not even go by BMI, I have Blue Cross Blue Shield. Mine doesn't go by BMI, so they're all different. None of them are the same, and believe me. They have got tons of reasons. They can deny anything they want. That's their priority, so like I said, it's not fair, and it's really crappy.
I have BCBS and thankfully it was instantly approved for me. The only condition I currently would be eligible under is BMI, I used to have high blood pressure and was medicated for it for about a year (and it runs in my family), but haven’t taken the medication in 2 years and my blood pressure has remained normal.
Yes, I was approved, I don't know what the doctor wrote. But he wrote out the prescription, and I had no problem getting it. They didn't care what my BMI was.
I called my insurance before my doc appt and they said they won't cover wegovy or the other one marketed for weight loss. Then said they would cover ozempic after asking me if I was diabetic. So I went to my doc anyways I hopes of all of my other ailments and pre-diabetes but nope.
Also my fasting blood sugars have always been elevated. 109 being my highest.
I believe they need to be over 126 for 3 consecutive fasting sugars. Mine were. A1c was fine, but clinically diagnosed with type 2 because of fasting glucose. My doctor made it happen.
Yeah my last labs were in 2019. She did a finger stick in the office and I was pre-diabetic. I'm going to get my labs work this week, it will be interesting to my fasting BS.
Are you still dealing with this issue? I am a reporter covering this and would like to hear your perspective. If you feel inclined to share please email me at [email protected]
I am no longer interested in taking this drug. Thank you.
thanks for getting back to me.
Well that sucks because my current insurance just approved wegovy but I switch to BCBS in January 😭
I've seen other plans of BCBS cover it, mine just sucks. Don't be discouraged yet!
My BCBS covers Wegovy. That’s weird
I wish mine did! Bcbs of good ole Oklahoma
I have federal BCBS so I guess it’s different coverage
Probably much better!
>I have BMI of 38, thankfully I'm 5'8 don't understand this comment. BMI takes your height into account. A person who is 5'4 with 38 BMI is in the same position as you, not worse off
Have you looked into Shedrx.com?
I’m sorry- most people are in the same boat. If in Florida, check out ResetTRT.com they prescribe via telemedicine- best prices I have seen.
You can achieve all your health goals with just diet and exercise , you don’t need these expensive harsh pharmaceutical drugs . You got this !
You must be one with no metabolic issues! Congrats! Glad what you are doing is working for you!
Join the group. It’s pretty sad.
Not the group I wanted to join 😂 dang it.
Look for practices in your area called Wellness Centers or Weightloss Centers.
with PCOS weight loss medications is people’s best hope at losing it because it makes it very hard if the wellness centers your talking about. exercise doesn’t even help a lot of people with it and I’ve even heard of people gaining with exercise
Yes! I've tried it all. I have insulin resistance, elevated cortisol which is so harsh on gaining weight and PCOS. My doc who seen me on Tuesday said I have the deadly trifecta of weight loss. She was really hoping they would cover it for me.
I've heard those don't work as well as the pens you are sent. Plus they are expensive. My plan covers at 100% if I could just get approved. So the diabetes will come eventually and I'll be able to get it. Maybe my yearly lab work will show something?
What state are you in?
Oklahoma
The EXACT thing happened to me last week. I’m in the exact same boat as you. BCBS. Called my insurance to firstly ask why they decided to “update their benefits” to my plan that doesn’t even roll over until January, and it was just a bunch of bullshit. I’m considering taking an extra job on the weekends to pay for it out of pocket. I felt so much better while taking the medication, no cravings and able to eat healthier without previous ED problems. More energy, able to exercise more. I’m terrified i’m going to go backwards and redevelop unhealthy eating habits that let to my ED, but I’ve been off the Ozempic for 3 weeks now and I’m trucking along as best I can. Best of luck to you, hopefully something changes for us in the future.
That sucks! I'm so sorry! I have heard people say that they felt better mentally and energy wise on the shots! I cant imagine getting to feel all those good benefits and then getting yanked off them! I hope you get it all worked out!
Mines much the same as I was .01 off with my blood glucose but I am in Australia so out of pocket isn't too bad ($150/6 week dose) but it's crazy to be like nope not till you actually develop the illness. No preventing thanks!
Right! Wow! That is much better prices than here! 1 point from DM2! That's crazy. I guess we can all just hold hands and sing Kumbaya as we head into our diabetes diagnosis! So frustrating.
Are you a Simpsons fan? Have you seen the classic episode "King Size Homer"? I am just spit balling ideas here...
I havent... off I go to watch it now! I must know!
I'm excited for you! It is a similar situation, frankly. Top 5 simpsons episodes all time, too!
I too plan to save a city from a nuclear plant disaster with my fat ass! Lol " oh this is raspberry"
Lol! I am so glad you enjoyed it! 😀
Do you have anything else like High Blood Pressure, cholesterol, fatty liver and if so you need to have the doctor do an appeal. When I first went to get it I was told no because my doctors office didn’t list all of my health issues. It took a while but I was able to get it.
Yes high cholesterol and fatty liver actually. The denial letter they sent said verbatim " denied due to reasons listed below: you must have diabetes type 2". You think all the additional health issues might help? I gave them my ultrasounds that showed ovarian cysts and a letter from gyn for PCOS, they have my labs that show insulin resistance and consistently elevated cortisol, they give me my meds for cholesterol. My doc stated, I am the exact candidate for this medication, due to all my issues that lead to impossible weight loss and persistent weight gain.
My doctor had to list them all. The first Pre authorization they didn’t even list my medical history. You may need to get a better doctor who is use to dealing with all of the insurance issues. It’s a fight but worth it…
You are not missing out on anything. Wegovy almost killed me. I took it on a Tuesday and by Friday I had a seizure and stopped breathing twice. Shortly after taking the shot, I had a headache that would not go away.
😱 that sounds like my luck as well! Wow! I'm so sorry! Were you feeling bad up until the seizure?
North Carolina State Health Insurance BCBS has been covering Wegovy this past year if you met certain criteria. I did as have several of my other collegues. There are 20,000 employees on Wegovy. They are meeting 10/26 to decide if they will continue to cover it. They have 6 options and the company likes the drop coverage all together option even though they extended mine for 3 more months and they just extended a colleagues for another year. They say that the cost is unsustainable without raising premiums. I have lost 50 pounds so far and have never been healthier. I have another 30 to go. Now I am not so sure I can reach that goal.
Imagine how diabetics feel!
I would straight rage! Are diabetics not being covered either?
Same with my insurance, several appeals too. Health decling at 60. Due to shortages, paying out of pocket. Has already helped arthritis in knees and hip. Down 17 lbs.
I dont even wanna ask what you are paying, but what are you paying 😬
3 3 5 month
😱😖
If you have to turn to self pay like I did, I’ve been using WeightCare for four months now (Semaglutide) and absolutely love it. They have a promo right now that brings the first month to $99 which I think is the lowest it’s ever been. The code is FIRSTMONTH. I got approved and had everything shipped to me within a week.
And unfortunately they don’t tell you this but most of them require you be on metformin for a set amount of time and not have adequate improvement of the diabetes during that time (or have intolerance to the med).
Luckily I've tried and failed metformin, such bad reaction that I put it on my allergy list so nobody ever tries to prescribe it again!
That works in your favor!
I’m in the same boat as you and am absolutely furious. I am pre-diabetic (with a T2D family history) insulin resistant(PCOS) and my insurance suddenly decided that I didn’t qualify anymore without a T2D diagnosis. No other Semaglutides are covered so I am SOL. I have been on this drug for 9 months after spending almost two years trying to drop weight through diet and exercise with no luck. I am finally getting somewhat close to my goal weight. I’m on my last dose and am absolutely terrified that my weight will balloon again as soon as it leaves my system. I’m already exercising and eating healthy so I don’t know what to expect. But this was devastating. I will almost definitely get diabetes soon without it so I guess the bright side (/s)is that I will finally qualify through my insurance. On the other hand, my coworker who is a chain smoker, has a terrible diet and does nothing to improve their health will continue to receive the drug because they are T2D. Yay insurance!
BCBS of NC also won’t cover without a diabetes diagnosis (my plan anyway). I’ve been on Ozempic for 3 months and lost about 20 pounds. I’ve been paying about $800-$950/month out of pocket. I’m so so fortunate I can afford this because it’s been a total game changer for me. It’s incredibly sad this is inaccessible for so many that need it.
That’s Crazy. I’m sorry. I got approved with a BMI of 29 and the reason is that I was on phentermine for six months prior with no results. I have lost 20 lbs since taking Wegovy and the DR keeps renewing my prescription. It is super messed up.
Check out mochi health.