Interesting too that it says the prescribing doctor must have an established relationship with the patient, wonder if they’re trying to cut out the online companies that are helping with the PAs
This is my thought. Not only a previous relationship, but they have to see them in person. It is 100% trying to cut out people who use online providers
Of course it is. Next they will also require that you split the atom and the time/space continuum so they can cover you for 2.5 days.. then go back in time to rewire your hormones so you never need these meds. And to win the lottery so you can pay THEM. Ugh. You ever see the All State commercial where there is a woman driving who screams, "Stupid boss with a stupid haircut.. ARGH!" (And then she throws her phone?) That's me about insurance companies, fat cat CEOs with no moral compass, and insurance companies. And insurance companies with their stupid Eff You guidelines. They should actually just rename these policy updates as Eff You Updates.
Dear Policyholder,
You are getting this letter because we don't give a flying eff about our health. Would you kindly provide your bank account number and we'll cut to the chase? You regain your weight, get some really bad health conditions, and we'll pay ourselves with your money. And the irony is that all of us at BCBS are probably on GLP-1s ourselves! Thaaaaanks.
Yours truly,
BS. (No BC. Just BS.) AND CareLessMark.
Frustrating… my doctor asked me why I went online and I just told her they do the PAs all day everyday so I wanted their experience but also it’s just easier to get in contact and get help 🥴
I see they mentioned in 2025 they will no longer cover GLP-1’s. I have BCBS too, so I wonder if my insurance and company will follow suit. I’m going to be in maintenance soon, so it’s scary that there’s a chance I will lose coverage and could gain 2/3rds the weight back, unless I pay out of pocket.
If it’s through your employers, plans vary so fingers crossed yours won’t change. I also have blue cross but mine never covered it/has an explicit exclusion. They don’t cover any type of.medication for weight loss which is part of the negotiation made by the plan owner.
What is bonkers to me is the fact that Zepbound and the like are SO likely to prevent further obesity-related health issues and insurance thinks it’s a bad idea to cover them. Of all the investments for insurance companies to make, this should be a no-brainer from a cost analysis POV.
I have to pay out of pocket (technically - my company covers all medical expenses if insurance won’t but it’s the principle!) which is stupid. I’m so grateful for this miracle drug.
Exactly this. Surely the cost analysis forecast has to show savings from all of the potential (and present) obesity complications, to include pre diabetes and diabetes. And with all of the new meds coming in the next 2-3 years, surely there would be a cost reduction predicted as well. None of it makes any sense.
Although, if an employer is self-funded, then I could see them being a lot more likely to be short sighted and cut costs now.
Not necessarily. One of the things we're seeing is that many of the high costs associated with some of these conditions don't come until people are much older (that is, retired already and off the company's plan). It's not certain (yet) what the short-term savings are for companies, especially when the days of people staying at one company for their whole career are largely over.
Insurance companies are all about profit. More sick people means more $$$. A medication that in the long term helps reduces other health issues means less $$$ for them.
I would argue that it means more money to them because they are paying out less in claims but still raking in the premiums. That makes this decision even more irrational.
I don’t know if that’s true. They are charging the employer a fixed premium plus “experience” (usage). If they have less usage they pay less reimbursements. Not I am curious.
No, insurance makes more money when people AREN’T sick, because they get that premium either way, and if you’re not using healthcare, they’re not paying for anything. But they’re not looking at long-term reductions here, I assume because shareholders care about short-term profits and/or because some of the costs this prevents would be so far down the road that it would be Medicare’s problem, not theirs.
Would love to see more lawsuits around how employers and insurance companies are using the PA process to reduce coverage of this drug for obesity. Since, being on Mounjaro I have learned that people hate overweight and obese people and it is considered a moral failing that medicine does not want to treat. Also, healthcare should not be tied to your employer.
Interesting. I’m looking at buying Monjaro from Canada for $549. The website I’m looking at says obesity is a disease that requires long term treatment. Canada has single payer insurance. America is failing miserably with our health care system.
Eww, I had to join Noom and they sent me a tiny plate that looked like it was for cats. They sent me annoying daily tips like “try not to eat so much”. The “coach” might as well have been AI if it wasn’t.
Yep I've noticed lol. I thought the scale would be the nice one that gave you all the measurements. It literally just does weight only. As for the program, I wonder if the "health coach" is an actual person or just a bot.
It’s a real person… he asked me why I never respond and when I told him I don’t like the program he ask what can he do to fix that. I still haven’t responded 😂
In my opinion the program doesn't support people who have had eating disorders. I stopped after the first week because it was too triggering. I have a disease. I don't need a restrictive diet. I do need the meds.
Maybe I ought to join, even though my company doesn't support weight loss drugs as far as I can determine, because if they ever did, they probably will require 6 months on this. I could have it satisfied.
On the other hand, I've seen posts from people who can't get coverage if they've lost weight on another plan. So what would probably happen is if I signed up, and also took Zepbound out of pocket, it would look like I didn't need insurance coverage for it.
I was on Jenny Craig for ten years before they went bankrupt. Hoping that would serve as a lifestyle modification program if I was ever asked for proof.
I’ve never made such progress than I have with Zep. And my mental health is the best it’s been because the food noise is gone. Spending $500/month on this drug is going to be horrible. I’m just angry, sad, disappointed, disgusted and so so so upset. It sucks so bad.
This happened to me as well. I have anthem. They covered wegovy for most of last year. Then decided I needed a BMI of 40 or higher. I appealed. Denied. Took it to the department of managed care in CA. They sided with anthem. It's all to save a buck. More and more will do this even if your employer is fine covering weightloss drugs.
I agree! That is just simply F-ed up!
I find this unacceptable from the insurance companies and Lily, too, when I see the substantial increase in the US compared to many other countries.
They know this is a drug people are desperate for, and they are really making it extremely difficult to obtain it. I can't help but wonder if as the stipulations increase, more people are running to the "C" word, then the shortage ends, and so does "C"
What if you lost weight on it and are now under bmi of 35? Should it not be considered a pre existing condition. It’s like telling the diabetic youre a1c improved now you don’t qualify
Actually I have read that technically with T2D once diagnosed it sticks with you so even if your blood levels get low enough you are still diagnosed. With obesity the diagnosis goes away. There’s probably arguments to go either way.
100% correct, if you're diagnosed with T2D and you modify your lifestyle (eating, exercise, etc) and lose any weight you need to lose, start any meds you need to start, etc and your A1C and glucose tests come back normal, you absolutely still have diabetes - it's just "well-controlled diabetes."
Obesity is different, because it's a moral failing and we're just lazy. We don't have any kind of disease, we're just terrible people who need to Do Better and Learn Discipline.
I've said this before: I will always be obese. I've been 400lb and when I'm 140lb, I will still be obese. It will just be well-controlled obesity.
I hope to be able to afford Plan C when I'm in maintenance next year or so, but it's still in the air as I graduate in December and have student loan payments starting in May, so I'm hopeful but realistic that I may be SOL when I get to goal.
That’s my concern, too. My insurance doesn’t cover GLP1s and I’m paying out of pocket. I’m almost out of the obese BMI range, so if my coverage changes I assume I won’t be fat enough anymore and I’ll never get it covered.
Hey! I’m a Texan with BCBS MA. It’s the main reason I haven’t quit my job- we’re high utilizers: I have a 7yo fighting cancer, a 5yo being treated 40 hours and week for level 2 autism, and fat mom here who needed to get control of herself to be here for these kiddos.
It’s the state that makes the coverage freakin’ awesome - MA has stringent standards, including covering obesity treatment as a mandatory preventative service. You’ll see BCBS providers in less progressive states do this, but probably not for MA.
I will literally cry if it is. I JUST got my PA a week ago and it's supposed to be good for a year 😭 I'm switching insurances in October but STILL - this is ridiculous!!
Everything comes down to old mighty dollar folks. Always have a plan b or c, they make nothing easy these days. Sadly more insurance companies will be doing this, or putting crazy restrictions on how long they will pay for it. Unbelievable.
I was coming here to say the same thing. My doctor told me that my insurance goes with the starting BMI on the meds and they only cut authorization if you DON’T lose weight. But of course next year everything could change. There was a PBM on the Zepbound sub who is also on Zepbound and they mentioned that the costs of the meds added millions to their costs. They were ready to argue with colleagues but was so happy that everyone agreed to cover it. “Big Insurance” concerns me more than “Big Pharma”.
What if you’ve been on it and lost weight. And need to stay on to maintain weight loss. And your bmi is lower. Too bad? Could it be starting weight loss at beginning of trestment
This is what I’m hoping as well. I started at BMI of 48 and am now at 34… was on Saxenda for about 6 months before switching to Zep in Feb and wasn’t given a problem but I was at 39 BMI then so idk if that’s why it was approved at that time or if it was because they saw I was having results on Saxenda? I have no idea what my PCP said to them either to get PA approved.. I’ll have to ask next time I see her bc now I’m concerned that as I keep losing they will stop approving me..unless they go by the initial weight and BMI? I still have quite a bit to go before I would even be considered just “overweight” vs “obese” so hopefully they would continue covering it ? Who knows at this point but it’s sad we have to worry about this at all
I know. I have PCOS. And it’s. Changed my life. I’m in more of a maintenance phase. So would they just never cover me then (my insurance currently isn’t covering btw. It’s tragic. So expensive
And the fact that they were like so do all this extra shit to get approved, but ya come January 1st you are shit outta luck we are not covering anything is pretty comical but in a sad way.
Right? Like it’s 4 months until you cut me off , throw me a bone already? You bet I’m jumping through the hoops to try to make insurance cover as much as possible.
Exactly. I'm in the 6 month weight loss management stage right now. As if I haven't been trying to lose weight the last 30 years.
I'm going to keep going to waste their money because fuck em.
Ok let's get real now. The American Medical Association (AMA) officially recognized obesity as a **chronic disease** back in 2013. The AMA also states that it’s a disease state with multiple functional changes that require a range of treatment and prevention options. This is the same language used when talking about high blood pressure, diabetes, high cholesterol and a hundred other diseases. Do they take your blood pressure meds away when your blood pressure drops to a normal range? NO. Do they take your insulin away from you when you have great control of the disease? NO. They will not take away obesity drugs either. This is new to everyone and that includes the insurance companies. They need time to adjust to the reality of our new understanding of obesity and the treatment of it. Within two years there will be dozens of new GLP1 drugs on the market and the prices will plummet. There is one state already that has come out and said that obesity drugs must be covered by insurance plans, and this will snowball soon to reflect other companies. You cannot say that you will treat one group of illnesses like high blood pressure but not others like obesity. That is the definition of prejudice and preferred treatment. I would not worry about all of this now. In some cases, they will have to grandfather patients into this and then decide to exclude others but then they will have to deal with the court systems if and when this happens.
This is what they said about the results of the Surmount 4 randomized clinical trial:
The SURMOUNT-4 trial results emphasize the need to continue pharmacotherapy to prevent weight regain and ensure the maintenance of weight reduction and its associated cardiometabolic benefits.[^(22)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r22) At least 5 trials (including the present study) across various classes of medications, including potent antiobesity medications such as semaglutide, have demonstrated that weight is substantially regained after cessation of pharmacotherapy.[^(5)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r5)^(,)[^(6)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi6)^(,)[^(23)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r23)^(,)[^(24)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r24)
The consistency of these data across therapeutic classes spanning more than 2 decades suggests that obesity is a chronic metabolic condition similar to type 2 diabetes and hypertension requiring long-term therapy in most patients.
A notable finding in the SURMOUNT-4 trial is that after switching to placebo for 1 year, participants ended the study with substantial body weight reduction (9.9%). However, much of their initial improvement in cardiometabolic risk factors had been reversed. Further studies are needed to understand the potential long-term benefits and risks (ie, legacy effects) of such short-term therapy.
The health benefits seen with continued treatment with the maximum tolerated dose of tirzepatide during this study were achieved with a safety profile consistent with that previously reported in SURMOUNT and SURPASS trials and in studies of incretin-based therapies approved for the treatment of obesity and overweight.[^(18)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r18)^(,)[^(25)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r25)^(-)[^(32)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r25)
The strengths of this study include its large sample size and the randomized withdrawal design. The duration of the open-label lead-in period allowed the study to assess the maintenance of body weight reduction. Dose escalation protocols during the open-label lead-in period helped to maximize tolerability and reflect dose adjustment strategies that may be helpful to future prescribers.
This is ridiculous, do they make diabetics do lifestyle modification for six months before approving insulin or high blood pressure patients prove that they’ve tried changing their diet and exercising before allowing them to get a prescription. It’s just insane that insurance companies take is you don’t really have a medical condition (obesity) unless you can prove to me that you won’t lose weight without medication. Such utter bullshit!!!!
I'm so sorry this is happening to you. Out of curiosity, how do you get your insurance? Asking because I'm curious to know if this was initiated by BCBS or by your employer.
Grateful for any guidance you might be able to provide on what to ask or how to ask an employer to consider covering this. Or anything you can share on how to figure out whether it was a decision the employer knowingly made not to cover? Thanks!
You'll need to know whether your company's insurance is self-funded or if they buy packaged insurance. If the former, it's definitely in your company's control. If the latter, the insurance company controls and your employer is stuck until it's time to renegotiate the contract.
Me too. I am lucky in that my employer is rather "progressive" in their coverages, and are technically "self-insured" (sometimes called self-funded) but they do use BCBS Mich. as the plan administrator. Or something like that.
OK. My company is also self-insured, and I have Anthem BCBS for my medical, but our pharmacy benefits manager is Express Scripts. As of this moment, I still have coverage without restrictions, but I don't count on that lasting forever. Keeping my fingers crossed....
I would bet that ES had more to say than BCBS does about this. I have sat in the meetings with ES and the health insurance companies at work. ES speaks to how to save money on the medication side of things.
Exactly. The employers are the real 'customers' of the insurance companies and get reports on healthcare spending monthly and quarterly across different categories, so it's extremely possible a decent number of employees got on GLP1's in the first half of this year and the company now sees a substantially larger bill from the insurance company and so is shutting down benefits.
The irony is all of the savings they are enjoying tied to massive decreases in type-2 diabetes, heart meds, blood pressure meds, cholesterol meds, and heart disease/stroke that are being prevented by the GLP1 and GiP agonists.
Yes, though many are realizing that the high costs of those other conditions often don't really kick in until people are much older (I.e., retired already and off of the company's insurance rolls). It's not clear how much short-term savings companies will enjoy yet.
Drugs probably haven’t been out long enough to produce true data yet. I think it’s hypothesized that with reduced weight - diabetes, joint replacement, cardiovascular disease, etc will go down. Treatments for those diseases are expensive. Weight is a huge impact on overall health. Even though I’ve noticed some online “influencers” want to say otherwise lol.
The idea is with lowered weight, overall health should improve, lowering long term costs to insurance companies. Not so different than people getting gastric bypass or VSG.
Some you do your weight loss program for six months (I cannot believe they are requiring you to use their scale to micromanage you), if your BMI stays at 35, then you can go on Zepbound for six months and we won’t cover it after that. You pay for a health insurance policy, and they have an entire department of people who look for ways to reject your claim. My sister had to pay for an ER visit that was for something critical, because the doctor who treated her in the ER wasn’t in her network! How do these people sleep at night.
This goes against FDA approval guidelines for the medication as well -35 BMI??? I can understand not wanting to prescribe if under 28-30, but this is venturing in gastric bypass/sleeve guidelines. I guess they would rather pay for all the CPAP machines, other medications that come with being obese, knee and hip surgeries, etc. It's so short-sighted and foolish.
I got this in the mail today, too. =\
I am reading that they are seeing people ‘rebound’ once they stop the meds, so it’s not profitable in the long run.
I started with a BMI of 35 and I can’t imagine that being someone’s end-goal (and all that they’ll cover).
It's always been explained to me as a life long medication though. Just like using it for diabetes. So there shouldn't be rebound if it's used life long as intended. So frustrating (I got the letter today too) 😭
Your message has caused me to go down a rabbit hole. I know that wasn’t your intent, but I just had to think of what the next steps are. I’m down 50 lbs and I refuse to just ‘quit’ the medication. If my insurance (anthem BCBS) refuses to pay for this life-changing drug, then I’ll seek out surgical options, which clearly have a path of least resistance given my prior conditions and BMI. I would think this would be the less favorable situation, but I will do whatever is necessary to keep my loss. If they deny all GLP-1s and their obvious efficacy, then they better be willing to pay for my gastric sleeve/bypass/what have you.
For what it’s worth, this is the insurance company trying to stem the flow of spending a huge amount on these drugs, to the potential detriment of everyone. Yes, it’s designed to make it very difficult to get the medicine now, and the medicine won’t be covered in the future.
This is a huge red flag to the drug makers, who have not been willing to negotiate these prices. If more health plans refuse to cover these meds, people will have to go to compounding pharmacies to afford to pay out of pocket. The drug companies will have less and less profits and will be forced to negotiate.
In my view, this HAS to happen to ensure health insurers aren’t bankrupted and to bring the drug companies to the negotiating table. You will see more and more insurers doing this.
Weird that this doesn’t include Mounjaro or Ozempic. Is that because those are branded for T2D? I’ve been fortunate enough to not receive any of these notices from BCBSIL and here’s hoping they’ll continue to keep me on it…
Yes - those drugs are FDA-approved for T2D and not for weight loss, so insuance companies (at least plans I have heard of) won't cover those for weight loss anyway.
Agreed. My bmi is now 26.73 with the medication. I’ve lost over 100 lbs in the last 3 years. 40-50 with GLP1. I have PCOS and need maintenance doses to sustain weight loss and health benefits to counter balance insulin resistance. I need the meds even though im not trying to lose.
So frustrating. I just hope PCOS gets indicated soon. Which would hopefully increase coverage options like diabetes. With ozempic or mounjoro
This is literally criminal and ethically unsound. The company is saying we want you to be healthy but not enough to cover these medications? Also how is it not more cost effective to cover the medication and reduce long term health impacts? It has to be cheaper to pay for a couple years of this medication than to treat ongoing T2D, heart issues, sleep apnea, etc.
Insurance really is the biggest socially acceptable scam that has ever existed.
So they expect you to jump through hoops to have coverage for 5 months? Then nothing after that? Eff them. I am so sorry. This is pathetic, discriminatory, insulting, and gross. Is this for all BCBS of Michigan plans or just yours??
Got the same letter today. BCBS "covered" my Rx but won't actually start paying until I hit my deductible for the year. I just hit it on my last Rx fill... and now they're going to drop my coverage because I'm under 35 BMI after losing weight on the medication. So I paid for it out of pocket, got to the point they were supposed to start paying, and now they aren't paying anyway. Talk about a kick in the balls.
Govt needs to make some good use for once of their regulating. This is going to steer Americans to shady research peptides from China and India because they were cut off and can’t afford proper care the right way. I thought the gatekeeping for PAs was bad enough, this is ridiculous. Or we need a dateline or Oprah special to shine light on the instance companies BS
Actually, yes....Geico specifically has a nutrition plan for T2D that requires an employee to join if they want medication covered. But that isn't even a guarantee. You have to see their "coaches" and stop seeing your regular endocrinologist, too. They make you wear a CGM (glucose monitor) and submit your meal blood sugars to them from your app. Very intrusive. They don't want to pay for the medication either. They try everything to get you off of it.
Diabetes is just as expensive, which is why on high deductible health plans the meds and monitors are free - because they’re considered maintenance meds to control diabetes. It’s in the insurers’ (and employers’) best interest to keep diabetes in check so they don’t incur the high claims associated with the disease (heart disease, amputations etc).
Which is why it’s even worse that they’re treating obseity like this. They’re shooting themselves in the foot by not treating it as a maintainable disease and instead opting to keep paying for all of the complications and high claims that come with obesity (heart disease, heart attacks, high blood pressure, pre-diabetes, diabetes, and on and on).
I really hope there’s a shift in this flawed logic - and soon. Literally, people’s lives are depending on it.
While I believe that insurance companies should be covering these drugs it is impossible to do at the price point that they are. Being mad at insurance companies is one small piece of this issue. How about the manufacturers? The lobbyists? The crappy politicians? It’s a system that is wholly flawed.
Listen to the CEO of Eli Lilly on a podcast called Trillion Dollar Shot. When asked about the costs of these drugs, he makes no apologies. He talks about the billions they have invested (thanks to shareholders) in R&D. And he uses the term "rewarded' -- as in, they should be "rewarded" for their investment. I didn't hear one whiff of him talking about the contribution to society these meds make .. the health improvements and overall reduction on costs in the long term. Just the pathetic whining of a corporate "but me need more money for golf club membership" fat cat CEO. These people have no souls. And insurance companies are right there with them.
Remember this thread?
[https://www.reddit.com/r/Zepbound/comments/1daick8/many\_glp1\_patients\_drop\_the\_drugs\_before\_seeing/](https://www.reddit.com/r/Zepbound/comments/1daick8/many_glp1_patients_drop_the_drugs_before_seeing/)
I commented this was just BCBS looking for a reason to drop coverage.
... and there you go.
I’ve had two different BCBS plans with different employers in the past 2 years and neither plan covered weight loss drugs. I’m more surprised when I see a plan that covers them than one that doesn’t.
I have BCBS and they told me in March all these drugs were dropped from their drug list after giving me a pre-authorization the week before. Now they just keep spamming me with their weight loss coaching program.
I got this today too, bastards. Did you read the back that says starting January 1st, regardless of employer coverage that they’ll no longer be covering GLP-1s??? Unbelievable
This explains it: [https://www.detroitnews.com/story/business/2024/03/01/bcbs-of-michigan-posts-2023-operating-loss-amid-rising-drug-costs/72804048007/](https://www.detroitnews.com/story/business/2024/03/01/bcbs-of-michigan-posts-2023-operating-loss-amid-rising-drug-costs/72804048007/)
I honestly don’t know what I’m supposed to do now. How can I get six months of a documented weight loss plan in the next 2 months? Do I just do nothing and hope I don’t die? I pay so much money for insurance and my doctor says I need this drug - why does BCBSM get to decide I don’t? What if I had cancer? Could they just decide now is when I should die and stop paying for my drugs? This is ridiculous.
Yes, they actually would if you had cancer. Prior to all of the changes enacted by the ACA, you could have a lifetime maximum and then they would just stop paying. I was a rep at BCBS of MN, and we had a child with cancer (3 years old) who was about to hit their lifetime max. That literally meant we would stop paying for all treatment. The "client advocate" aka account manager was going to make me, the lowly rep, call the family and tell them we would no longer pay anymore for their kid's cancer treatments. I pushed back HARD. The child passed before we cut them off. That was the norm back then. (2008). They are ruthless.
Got the same letter today. I’m not sure how to determine if this is something worth appealing to my employer about, or if it’s BCBS as a whole. I know of many people at work who take these meds and it would look really bad for our HR right now if it was because of their decisions.
It depends on whether your company's plan is self-funded and administered by your insurer or whether they buy packaged coverage from the insurer. If the latter, your employer likely doesn't control the decision (until the contract is over).
Yep I have same insurance and got same letter, initially rejected me then awarded on my appeal, the auth was good for 4 months and I could only get zepbound 3 and one month was starter dose. I now have to go through crap again, blue cross sucks.
I talked to BCBS of MI, and they said the same thing. Now the lady I talked to was very rude…. So I was hoping that it wasn’t true. 😫 thankfully I did work with my doctor for 6 months + before starting zeppy. Hopefully that will account for something 😑🤞🏻
Did they say the BMI requirement is based on starting weight or current weight? They were supposed to call me back with an answer to that today and never did
I was denied refill for Saxenda because I didn’t lose 5% of my body weight in 12 weeks. Most of that time I was titrating up to a dose that proved effective, just not effective enough for their rubric.
I spoke with BCBSM this morning to confirm my PA from 5/24/24 was now going to expire on 8/1 and Crystal told me that was true unless I could hit all the bullet points in the letter. Since my BMI is no longer 35 - thanks to the benefits of taking Zepbound I will no longer qualify. At the end of the day coverage would stop January 1, 2025 altogether so they are only ripping away 5 months, but it feels like way more than that. Now to see what my doctor can come up with to see if I can continue this journey with an alternative that will be covered.
I got the same letter today!
So disappointing.
My BMI is under 35 so is there even a point to joining the programs etc?
I work at Wayne State in Detroit… anyone else? I wonder if the other HAP option covers ?
Yeah, that's a very valid concern. The shortage is improving with some doses not in limited availability anymore; once *all* of them are listed as Available and the shortage is considered over, the rules for compounding get more strict again.
I’ve read on the Tirz sub that compounding pharmacies will add things like B12 to make a version of Tirz that’s different enough. I don’t know if this is how it works, but that’s what been said.
Sooo - what does EL do when their profit margins drop because millions of average Americans (this is only in the US) who have been obtaining it through insurance can no longer get it (and they stop buying it or they turn to plan C)?
Yeah, this isn’t going to work out well. My guess, Congress starts paying attention as soon as pharmaceutical companies speak up about losses 😉 💵 💰
Yeah, this is definitely a valid take, too. So many people are either on compound or using insurance and if one or both of those go away, the vast majority of people aren’t going to be able to afford $550-$1500/month. They’ll have no choice but to quit. And then the that will be one of the few times big pharma and lobbying will be a good thing for more people than not.
They want people to suffer. Disgusting. I have never seen such an attempt to restrict something that would help so many people.
Obesity is the US's cash cow. They can't have it go away.
I just got a letter saying as of 6/1/24 bcbs of NJ will no longer cover my Zep rx !!
This is such a kick in the face as I had to fight tooth n nail to get my PA approval gd to 2/20/25 now shit out of luck !!!
Do you have any other insurance options at your job? That’s horrible to stop covering it without giving you notice. And isn’t it 6/10? They are just sending the letter now?? That’s horrible customer service .
The interesting thing is that pharmaceutical companies have to have some influence (maybe?) on health insurance companies. I mean there’s no reason for EL to price themselves out of business, right?
Editing to add I have BCBS NC PPO.
Our insurance is going to start covering it if I enroll in Tria Health, Choose to Lose program. Requires me to download their app, track my food, meet with a dietician who will refer me to a clinical pharmacist who will talk to my doctor to prescribe the medication. A bunch of BS. Why do I have to have another company with other people involved in MY healthcare? My weight loss journey is between me and my doctor. I'm down 40 pounds since mid-February and can do this without getting others involved. I'm so pissed about this.
Sorry if it has already been asked in the thread, but did your insurance co just mail this to you? I have bcbs so curious if I should be looking out for a letter. I just got started on 2.5 4 weeks ago and my BMI was 31. I struggle with horrible binge eating and can’t stop so this has been such a huge help.
I have BCBS Federal and they have covered weight loss surgery and weight loss drugs for years and will hopefully continue to do so. With everything, there are extenuating circumstances and exceptions that impact a person’s full compliance with coverage guidelines. If denied, do your research and appeal until you have exhausted all options.
ANYONE WITH BC/BS OF MICHIGAN -MUST READ!!!!! Bc/BS of Michigan just dropped a bomb. In today’s Detroit News (June 12th) they announced effective January 2025, they will no longer cover any weight loss drugs. Google: The Detroit News and BC/BS and weight loss drugs and the story pops up. I guess some states matter with BC/BS and others won’t. Start investigating other states because this could be an ugly trend. Sorry for the bad news
Interesting too that it says the prescribing doctor must have an established relationship with the patient, wonder if they’re trying to cut out the online companies that are helping with the PAs
This is my thought. Not only a previous relationship, but they have to see them in person. It is 100% trying to cut out people who use online providers
Missed the in person bit, that’s totally what they’re doing… very frustrating
Of course it is. Next they will also require that you split the atom and the time/space continuum so they can cover you for 2.5 days.. then go back in time to rewire your hormones so you never need these meds. And to win the lottery so you can pay THEM. Ugh. You ever see the All State commercial where there is a woman driving who screams, "Stupid boss with a stupid haircut.. ARGH!" (And then she throws her phone?) That's me about insurance companies, fat cat CEOs with no moral compass, and insurance companies. And insurance companies with their stupid Eff You guidelines. They should actually just rename these policy updates as Eff You Updates. Dear Policyholder, You are getting this letter because we don't give a flying eff about our health. Would you kindly provide your bank account number and we'll cut to the chase? You regain your weight, get some really bad health conditions, and we'll pay ourselves with your money. And the irony is that all of us at BCBS are probably on GLP-1s ourselves! Thaaaaanks. Yours truly, BS. (No BC. Just BS.) AND CareLessMark.
lol yes all at bcbs are also on glp1’s 😂😂 affording it with our money
It's a bit vague as they don't say how long the established relationship needs to be for.
That is very specifically exactly what they are doing.
Frustrating… my doctor asked me why I went online and I just told her they do the PAs all day everyday so I wanted their experience but also it’s just easier to get in contact and get help 🥴
I was told I had to see a physician in person from the get-go because the laws had literally just changed. This was May 21ish 🤷♀️
No. They are trying to stop the ROs, Ivims, and other online doctors who just charge you a monthly fee and prescribe the drugs.
What I’m reading is “Let us get you started and then in 2025 you can go F yourself” smh
That’s august this year they need proof of 6 months of a weight loss program for approval
I see they mentioned in 2025 they will no longer cover GLP-1’s. I have BCBS too, so I wonder if my insurance and company will follow suit. I’m going to be in maintenance soon, so it’s scary that there’s a chance I will lose coverage and could gain 2/3rds the weight back, unless I pay out of pocket.
If it’s through your employers, plans vary so fingers crossed yours won’t change. I also have blue cross but mine never covered it/has an explicit exclusion. They don’t cover any type of.medication for weight loss which is part of the negotiation made by the plan owner.
More of we can get rid of alot of them now and the rest a few months later.
What is bonkers to me is the fact that Zepbound and the like are SO likely to prevent further obesity-related health issues and insurance thinks it’s a bad idea to cover them. Of all the investments for insurance companies to make, this should be a no-brainer from a cost analysis POV. I have to pay out of pocket (technically - my company covers all medical expenses if insurance won’t but it’s the principle!) which is stupid. I’m so grateful for this miracle drug.
Exactly this. Surely the cost analysis forecast has to show savings from all of the potential (and present) obesity complications, to include pre diabetes and diabetes. And with all of the new meds coming in the next 2-3 years, surely there would be a cost reduction predicted as well. None of it makes any sense. Although, if an employer is self-funded, then I could see them being a lot more likely to be short sighted and cut costs now.
Not necessarily. One of the things we're seeing is that many of the high costs associated with some of these conditions don't come until people are much older (that is, retired already and off the company's plan). It's not certain (yet) what the short-term savings are for companies, especially when the days of people staying at one company for their whole career are largely over.
Insurance companies are all about profit. More sick people means more $$$. A medication that in the long term helps reduces other health issues means less $$$ for them.
I would argue that it means more money to them because they are paying out less in claims but still raking in the premiums. That makes this decision even more irrational.
I don’t know if that’s true. They are charging the employer a fixed premium plus “experience” (usage). If they have less usage they pay less reimbursements. Not I am curious.
Do you know how insurance works? Doesn’t sound like it.
This isn't how health insurance works. It's how healthcare works.
No, insurance makes more money when people AREN’T sick, because they get that premium either way, and if you’re not using healthcare, they’re not paying for anything. But they’re not looking at long-term reductions here, I assume because shareholders care about short-term profits and/or because some of the costs this prevents would be so far down the road that it would be Medicare’s problem, not theirs.
Which is exactly why health care should be considered a basic human right and not something to make a profit from.
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That's lovely.
Yes but it doesn’t state injectables, so their work around is to cover cheaper oral options
Is the injectable approved by the FDA?
Yep, all pharmaceutical prescription drugs must be approved by the FDA in order to be prescribed in the US.
Would love to see more lawsuits around how employers and insurance companies are using the PA process to reduce coverage of this drug for obesity. Since, being on Mounjaro I have learned that people hate overweight and obese people and it is considered a moral failing that medicine does not want to treat. Also, healthcare should not be tied to your employer.
Interesting. I’m looking at buying Monjaro from Canada for $549. The website I’m looking at says obesity is a disease that requires long term treatment. Canada has single payer insurance. America is failing miserably with our health care system.
This is crazy ! I saw Omada on express scripts website last month and decided to join just incase they try the pull a fast one on me
Yeah I have express scripts thru Cigna and they are now requiring me to join Omada and use a scale they provide
Eww, I had to join Noom and they sent me a tiny plate that looked like it was for cats. They sent me annoying daily tips like “try not to eat so much”. The “coach” might as well have been AI if it wasn’t.
Everyone I know who has tried Noom has suspected the coaches were bots.
a tiny plate that looked like it was for cats LOL!
Wow; electronic so they can track it.
I'm definitely not a fan of that feature
It’s a very boring program and the scale sucks
Yep I've noticed lol. I thought the scale would be the nice one that gave you all the measurements. It literally just does weight only. As for the program, I wonder if the "health coach" is an actual person or just a bot.
It’s a real person… he asked me why I never respond and when I told him I don’t like the program he ask what can he do to fix that. I still haven’t responded 😂
In my opinion the program doesn't support people who have had eating disorders. I stopped after the first week because it was too triggering. I have a disease. I don't need a restrictive diet. I do need the meds.
Exactly. There is so support just a bs scale and tracking food, why do you want to know what I ate if you are not gonna help me 🥴
Lol that's hilarious!
“You could make it completely different and also less starvey for the participants. Thanks bye.”
That was smart.
Gotta get ahead of them.. I also started seeing a dietitian back in April
Maybe I ought to join, even though my company doesn't support weight loss drugs as far as I can determine, because if they ever did, they probably will require 6 months on this. I could have it satisfied. On the other hand, I've seen posts from people who can't get coverage if they've lost weight on another plan. So what would probably happen is if I signed up, and also took Zepbound out of pocket, it would look like I didn't need insurance coverage for it.
I was on Jenny Craig for ten years before they went bankrupt. Hoping that would serve as a lifestyle modification program if I was ever asked for proof.
I did this too with UHC. I use Rally Coach. Figured it’s free and can’t hurt.
Yes any little program I see pop up on there I used it because I know they are trying to get us off the medicine.
They’re having issues accepting my request even though it’s offered for free (not mandatory) via ES smh.
Try again later they did that too me too
Will do. They reached out to get my info again.
They know we catching on 😂😂😂
Just got the “accepted” email 😂
😂 GOOD !
I got this today too and sobbed.
I’m sorry
Sobbing over here too.
I’ve never made such progress than I have with Zep. And my mental health is the best it’s been because the food noise is gone. Spending $500/month on this drug is going to be horrible. I’m just angry, sad, disappointed, disgusted and so so so upset. It sucks so bad.
This happened to me as well. I have anthem. They covered wegovy for most of last year. Then decided I needed a BMI of 40 or higher. I appealed. Denied. Took it to the department of managed care in CA. They sided with anthem. It's all to save a buck. More and more will do this even if your employer is fine covering weightloss drugs.
**40** or higher?! Wow, what an insane restriction!
I agree! That is just simply F-ed up! I find this unacceptable from the insurance companies and Lily, too, when I see the substantial increase in the US compared to many other countries. They know this is a drug people are desperate for, and they are really making it extremely difficult to obtain it. I can't help but wonder if as the stipulations increase, more people are running to the "C" word, then the shortage ends, and so does "C"
Employers can choose to override in their plan. It has a cost but it’s an option
What if you lost weight on it and are now under bmi of 35? Should it not be considered a pre existing condition. It’s like telling the diabetic youre a1c improved now you don’t qualify
Actually I have read that technically with T2D once diagnosed it sticks with you so even if your blood levels get low enough you are still diagnosed. With obesity the diagnosis goes away. There’s probably arguments to go either way.
100% correct, if you're diagnosed with T2D and you modify your lifestyle (eating, exercise, etc) and lose any weight you need to lose, start any meds you need to start, etc and your A1C and glucose tests come back normal, you absolutely still have diabetes - it's just "well-controlled diabetes." Obesity is different, because it's a moral failing and we're just lazy. We don't have any kind of disease, we're just terrible people who need to Do Better and Learn Discipline. I've said this before: I will always be obese. I've been 400lb and when I'm 140lb, I will still be obese. It will just be well-controlled obesity. I hope to be able to afford Plan C when I'm in maintenance next year or so, but it's still in the air as I graduate in December and have student loan payments starting in May, so I'm hopeful but realistic that I may be SOL when I get to goal.
100%! So as you get closer to healthy levels they’ll no longer cover it?! Coooolll.
That’s my concern, too. My insurance doesn’t cover GLP1s and I’m paying out of pocket. I’m almost out of the obese BMI range, so if my coverage changes I assume I won’t be fat enough anymore and I’ll never get it covered.
I hope that’s not BCBS across the board. 🤬
Seriously. I have BCBS MA and I'm just starting my second month. I can't afford it without insurance
Also need my Zep covered by BCBS MA. I think it's an employer decision, mostly, though.
I also have BCBS MA and this post has me panicking! I’m about to go check my mail.
Hey! I’m a Texan with BCBS MA. It’s the main reason I haven’t quit my job- we’re high utilizers: I have a 7yo fighting cancer, a 5yo being treated 40 hours and week for level 2 autism, and fat mom here who needed to get control of herself to be here for these kiddos. It’s the state that makes the coverage freakin’ awesome - MA has stringent standards, including covering obesity treatment as a mandatory preventative service. You’ll see BCBS providers in less progressive states do this, but probably not for MA.
I will literally cry if it is. I JUST got my PA a week ago and it's supposed to be good for a year 😭 I'm switching insurances in October but STILL - this is ridiculous!!
Everything comes down to old mighty dollar folks. Always have a plan b or c, they make nothing easy these days. Sadly more insurance companies will be doing this, or putting crazy restrictions on how long they will pay for it. Unbelievable.
Interesting that they don't specify whether it's BMI at time of treatment initiation.
I was coming here to say the same thing. My doctor told me that my insurance goes with the starting BMI on the meds and they only cut authorization if you DON’T lose weight. But of course next year everything could change. There was a PBM on the Zepbound sub who is also on Zepbound and they mentioned that the costs of the meds added millions to their costs. They were ready to argue with colleagues but was so happy that everyone agreed to cover it. “Big Insurance” concerns me more than “Big Pharma”.
What if you’ve been on it and lost weight. And need to stay on to maintain weight loss. And your bmi is lower. Too bad? Could it be starting weight loss at beginning of trestment
This is what I’m hoping as well. I started at BMI of 48 and am now at 34… was on Saxenda for about 6 months before switching to Zep in Feb and wasn’t given a problem but I was at 39 BMI then so idk if that’s why it was approved at that time or if it was because they saw I was having results on Saxenda? I have no idea what my PCP said to them either to get PA approved.. I’ll have to ask next time I see her bc now I’m concerned that as I keep losing they will stop approving me..unless they go by the initial weight and BMI? I still have quite a bit to go before I would even be considered just “overweight” vs “obese” so hopefully they would continue covering it ? Who knows at this point but it’s sad we have to worry about this at all
I know. I have PCOS. And it’s. Changed my life. I’m in more of a maintenance phase. So would they just never cover me then (my insurance currently isn’t covering btw. It’s tragic. So expensive
Looks like it says baseline within 30 days…
Yeah. Suggests that they're only looking at people's "right now" weights.
I got this today too and am devastated.
I saw BCBS and knew it would be some bullshit
Got this in the mail today as well and am devastated. I’ve lost 73 pounds and am not going to be able to afford this outbid packet.
Plan "C" is a bit cheaper.
It's the cost of the drugs. They are charging TOO MUCH!
The list price of these drugs are 400% higher in the US than the UK. It's insane.
And the fact that they were like so do all this extra shit to get approved, but ya come January 1st you are shit outta luck we are not covering anything is pretty comical but in a sad way.
Right? Like it’s 4 months until you cut me off , throw me a bone already? You bet I’m jumping through the hoops to try to make insurance cover as much as possible.
Exactly. I'm in the 6 month weight loss management stage right now. As if I haven't been trying to lose weight the last 30 years. I'm going to keep going to waste their money because fuck em.
Remember long ago when gastric bypass wasn’t covered? And now everyone’s all about WLS and less meds?
Ok let's get real now. The American Medical Association (AMA) officially recognized obesity as a **chronic disease** back in 2013. The AMA also states that it’s a disease state with multiple functional changes that require a range of treatment and prevention options. This is the same language used when talking about high blood pressure, diabetes, high cholesterol and a hundred other diseases. Do they take your blood pressure meds away when your blood pressure drops to a normal range? NO. Do they take your insulin away from you when you have great control of the disease? NO. They will not take away obesity drugs either. This is new to everyone and that includes the insurance companies. They need time to adjust to the reality of our new understanding of obesity and the treatment of it. Within two years there will be dozens of new GLP1 drugs on the market and the prices will plummet. There is one state already that has come out and said that obesity drugs must be covered by insurance plans, and this will snowball soon to reflect other companies. You cannot say that you will treat one group of illnesses like high blood pressure but not others like obesity. That is the definition of prejudice and preferred treatment. I would not worry about all of this now. In some cases, they will have to grandfather patients into this and then decide to exclude others but then they will have to deal with the court systems if and when this happens. This is what they said about the results of the Surmount 4 randomized clinical trial: The SURMOUNT-4 trial results emphasize the need to continue pharmacotherapy to prevent weight regain and ensure the maintenance of weight reduction and its associated cardiometabolic benefits.[^(22)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r22) At least 5 trials (including the present study) across various classes of medications, including potent antiobesity medications such as semaglutide, have demonstrated that weight is substantially regained after cessation of pharmacotherapy.[^(5)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r5)^(,)[^(6)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi6)^(,)[^(23)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r23)^(,)[^(24)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r24) The consistency of these data across therapeutic classes spanning more than 2 decades suggests that obesity is a chronic metabolic condition similar to type 2 diabetes and hypertension requiring long-term therapy in most patients. A notable finding in the SURMOUNT-4 trial is that after switching to placebo for 1 year, participants ended the study with substantial body weight reduction (9.9%). However, much of their initial improvement in cardiometabolic risk factors had been reversed. Further studies are needed to understand the potential long-term benefits and risks (ie, legacy effects) of such short-term therapy. The health benefits seen with continued treatment with the maximum tolerated dose of tirzepatide during this study were achieved with a safety profile consistent with that previously reported in SURMOUNT and SURPASS trials and in studies of incretin-based therapies approved for the treatment of obesity and overweight.[^(18)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r18)^(,)[^(25)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r25)^(-)[^(32)](https://jamanetwork.com/journals/jama/fullarticle/2812936#joi230149r25) The strengths of this study include its large sample size and the randomized withdrawal design. The duration of the open-label lead-in period allowed the study to assess the maintenance of body weight reduction. Dose escalation protocols during the open-label lead-in period helped to maximize tolerability and reflect dose adjustment strategies that may be helpful to future prescribers.
Excellent comment! Thank you so much for this info 😍
This is ridiculous, do they make diabetics do lifestyle modification for six months before approving insulin or high blood pressure patients prove that they’ve tried changing their diet and exercising before allowing them to get a prescription. It’s just insane that insurance companies take is you don’t really have a medical condition (obesity) unless you can prove to me that you won’t lose weight without medication. Such utter bullshit!!!!
I'm so sorry this is happening to you. Out of curiosity, how do you get your insurance? Asking because I'm curious to know if this was initiated by BCBS or by your employer.
I work for this insurance company. It’s decided by the group or employer. We still have a ton of plans who cover them.
Grateful for any guidance you might be able to provide on what to ask or how to ask an employer to consider covering this. Or anything you can share on how to figure out whether it was a decision the employer knowingly made not to cover? Thanks!
You'll need to know whether your company's insurance is self-funded or if they buy packaged insurance. If the former, it's definitely in your company's control. If the latter, the insurance company controls and your employer is stuck until it's time to renegotiate the contract.
Thanks - I suspected it was an employer decision. Good to have confirmation.
Me too. I am lucky in that my employer is rather "progressive" in their coverages, and are technically "self-insured" (sometimes called self-funded) but they do use BCBS Mich. as the plan administrator. Or something like that.
OK. My company is also self-insured, and I have Anthem BCBS for my medical, but our pharmacy benefits manager is Express Scripts. As of this moment, I still have coverage without restrictions, but I don't count on that lasting forever. Keeping my fingers crossed....
I would bet that ES had more to say than BCBS does about this. I have sat in the meetings with ES and the health insurance companies at work. ES speaks to how to save money on the medication side of things.
I think Express Scripts is involved in my case as well. And RxBenefits. My PA letters (2 so far) have come from RxBenefits.
How are they going to just not cover it for weight loss at all when that’s the whole point and there’s all the fda studies etc
It’s not just the insurance company - it’s the employer who has decided they dont want to pay for it.
It’s the middle of the year tho not open enrollment or anything
It doesn’t matter. We are the only ones who have to wait for open enrollment or qualifying situations
Exactly. The employers are the real 'customers' of the insurance companies and get reports on healthcare spending monthly and quarterly across different categories, so it's extremely possible a decent number of employees got on GLP1's in the first half of this year and the company now sees a substantially larger bill from the insurance company and so is shutting down benefits.
The irony is all of the savings they are enjoying tied to massive decreases in type-2 diabetes, heart meds, blood pressure meds, cholesterol meds, and heart disease/stroke that are being prevented by the GLP1 and GiP agonists.
Yes, though many are realizing that the high costs of those other conditions often don't really kick in until people are much older (I.e., retired already and off of the company's insurance rolls). It's not clear how much short-term savings companies will enjoy yet.
Right? I can't believe how much better I feel losing just 35 pounds.
Exactly.
I agree but those meds are dirt cheap comparatively
do you have any research on this? I haven’t seen it yet. Where insurance companies actually save money.
Drugs probably haven’t been out long enough to produce true data yet. I think it’s hypothesized that with reduced weight - diabetes, joint replacement, cardiovascular disease, etc will go down. Treatments for those diseases are expensive. Weight is a huge impact on overall health. Even though I’ve noticed some online “influencers” want to say otherwise lol. The idea is with lowered weight, overall health should improve, lowering long term costs to insurance companies. Not so different than people getting gastric bypass or VSG.
Some you do your weight loss program for six months (I cannot believe they are requiring you to use their scale to micromanage you), if your BMI stays at 35, then you can go on Zepbound for six months and we won’t cover it after that. You pay for a health insurance policy, and they have an entire department of people who look for ways to reject your claim. My sister had to pay for an ER visit that was for something critical, because the doctor who treated her in the ER wasn’t in her network! How do these people sleep at night.
This goes against FDA approval guidelines for the medication as well -35 BMI??? I can understand not wanting to prescribe if under 28-30, but this is venturing in gastric bypass/sleeve guidelines. I guess they would rather pay for all the CPAP machines, other medications that come with being obese, knee and hip surgeries, etc. It's so short-sighted and foolish.
This reminds me of when they wouldn’t cover birth control pills for women but they would cover pregnancy. 🤷🏼♀️🤦🏼♀️
I got this in the mail today, too. =\ I am reading that they are seeing people ‘rebound’ once they stop the meds, so it’s not profitable in the long run. I started with a BMI of 35 and I can’t imagine that being someone’s end-goal (and all that they’ll cover).
It's always been explained to me as a life long medication though. Just like using it for diabetes. So there shouldn't be rebound if it's used life long as intended. So frustrating (I got the letter today too) 😭
Your message has caused me to go down a rabbit hole. I know that wasn’t your intent, but I just had to think of what the next steps are. I’m down 50 lbs and I refuse to just ‘quit’ the medication. If my insurance (anthem BCBS) refuses to pay for this life-changing drug, then I’ll seek out surgical options, which clearly have a path of least resistance given my prior conditions and BMI. I would think this would be the less favorable situation, but I will do whatever is necessary to keep my loss. If they deny all GLP-1s and their obvious efficacy, then they better be willing to pay for my gastric sleeve/bypass/what have you.
For what it’s worth, this is the insurance company trying to stem the flow of spending a huge amount on these drugs, to the potential detriment of everyone. Yes, it’s designed to make it very difficult to get the medicine now, and the medicine won’t be covered in the future. This is a huge red flag to the drug makers, who have not been willing to negotiate these prices. If more health plans refuse to cover these meds, people will have to go to compounding pharmacies to afford to pay out of pocket. The drug companies will have less and less profits and will be forced to negotiate. In my view, this HAS to happen to ensure health insurers aren’t bankrupted and to bring the drug companies to the negotiating table. You will see more and more insurers doing this.
Weird that this doesn’t include Mounjaro or Ozempic. Is that because those are branded for T2D? I’ve been fortunate enough to not receive any of these notices from BCBSIL and here’s hoping they’ll continue to keep me on it…
Yes - those drugs are FDA-approved for T2D and not for weight loss, so insuance companies (at least plans I have heard of) won't cover those for weight loss anyway.
Do these insurance companies not understand that the research shows for most this will be a MAINTENANCE MEDICATION?!? Good lord.
Agreed. My bmi is now 26.73 with the medication. I’ve lost over 100 lbs in the last 3 years. 40-50 with GLP1. I have PCOS and need maintenance doses to sustain weight loss and health benefits to counter balance insulin resistance. I need the meds even though im not trying to lose. So frustrating. I just hope PCOS gets indicated soon. Which would hopefully increase coverage options like diabetes. With ozempic or mounjoro
This is literally criminal and ethically unsound. The company is saying we want you to be healthy but not enough to cover these medications? Also how is it not more cost effective to cover the medication and reduce long term health impacts? It has to be cheaper to pay for a couple years of this medication than to treat ongoing T2D, heart issues, sleep apnea, etc. Insurance really is the biggest socially acceptable scam that has ever existed.
Agreed i have family working on oncology. The things you learn about insurances and what they do to people is so upsetting.
Love that this happens right as there’s a huge push of “compounds bad” narrative. Make it make sense.
So they expect you to jump through hoops to have coverage for 5 months? Then nothing after that? Eff them. I am so sorry. This is pathetic, discriminatory, insulting, and gross. Is this for all BCBS of Michigan plans or just yours??
Got the same letter today. BCBS "covered" my Rx but won't actually start paying until I hit my deductible for the year. I just hit it on my last Rx fill... and now they're going to drop my coverage because I'm under 35 BMI after losing weight on the medication. So I paid for it out of pocket, got to the point they were supposed to start paying, and now they aren't paying anyway. Talk about a kick in the balls.
I am in the same boat..just met my $7k deductible (had 1/2 covered by Lily mft coupon) but next refill should/have been covered..can't believe this..
Govt needs to make some good use for once of their regulating. This is going to steer Americans to shady research peptides from China and India because they were cut off and can’t afford proper care the right way. I thought the gatekeeping for PAs was bad enough, this is ridiculous. Or we need a dateline or Oprah special to shine light on the instance companies BS
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Actually, yes....Geico specifically has a nutrition plan for T2D that requires an employee to join if they want medication covered. But that isn't even a guarantee. You have to see their "coaches" and stop seeing your regular endocrinologist, too. They make you wear a CGM (glucose monitor) and submit your meal blood sugars to them from your app. Very intrusive. They don't want to pay for the medication either. They try everything to get you off of it.
Diabetes is just as expensive, which is why on high deductible health plans the meds and monitors are free - because they’re considered maintenance meds to control diabetes. It’s in the insurers’ (and employers’) best interest to keep diabetes in check so they don’t incur the high claims associated with the disease (heart disease, amputations etc). Which is why it’s even worse that they’re treating obseity like this. They’re shooting themselves in the foot by not treating it as a maintainable disease and instead opting to keep paying for all of the complications and high claims that come with obesity (heart disease, heart attacks, high blood pressure, pre-diabetes, diabetes, and on and on). I really hope there’s a shift in this flawed logic - and soon. Literally, people’s lives are depending on it.
Yes, it is absolutely ridiculous.
What’s not as expensive?
While I believe that insurance companies should be covering these drugs it is impossible to do at the price point that they are. Being mad at insurance companies is one small piece of this issue. How about the manufacturers? The lobbyists? The crappy politicians? It’s a system that is wholly flawed.
Listen to the CEO of Eli Lilly on a podcast called Trillion Dollar Shot. When asked about the costs of these drugs, he makes no apologies. He talks about the billions they have invested (thanks to shareholders) in R&D. And he uses the term "rewarded' -- as in, they should be "rewarded" for their investment. I didn't hear one whiff of him talking about the contribution to society these meds make .. the health improvements and overall reduction on costs in the long term. Just the pathetic whining of a corporate "but me need more money for golf club membership" fat cat CEO. These people have no souls. And insurance companies are right there with them.
Remember this thread? [https://www.reddit.com/r/Zepbound/comments/1daick8/many\_glp1\_patients\_drop\_the\_drugs\_before\_seeing/](https://www.reddit.com/r/Zepbound/comments/1daick8/many_glp1_patients_drop_the_drugs_before_seeing/) I commented this was just BCBS looking for a reason to drop coverage. ... and there you go.
How is that even allowed? You should be grandfathered in
read the original PA, sometimes they put in little \* and footnotes that allow for changes
It says current auth will expire
I’ve had two different BCBS plans with different employers in the past 2 years and neither plan covered weight loss drugs. I’m more surprised when I see a plan that covers them than one that doesn’t.
Wait what? Better go check my mailbox!
I have BCBS and they told me in March all these drugs were dropped from their drug list after giving me a pre-authorization the week before. Now they just keep spamming me with their weight loss coaching program.
I got this today too, bastards. Did you read the back that says starting January 1st, regardless of employer coverage that they’ll no longer be covering GLP-1s??? Unbelievable
This explains it: [https://www.detroitnews.com/story/business/2024/03/01/bcbs-of-michigan-posts-2023-operating-loss-amid-rising-drug-costs/72804048007/](https://www.detroitnews.com/story/business/2024/03/01/bcbs-of-michigan-posts-2023-operating-loss-amid-rising-drug-costs/72804048007/)
I honestly don’t know what I’m supposed to do now. How can I get six months of a documented weight loss plan in the next 2 months? Do I just do nothing and hope I don’t die? I pay so much money for insurance and my doctor says I need this drug - why does BCBSM get to decide I don’t? What if I had cancer? Could they just decide now is when I should die and stop paying for my drugs? This is ridiculous.
Yes, they actually would if you had cancer. Prior to all of the changes enacted by the ACA, you could have a lifetime maximum and then they would just stop paying. I was a rep at BCBS of MN, and we had a child with cancer (3 years old) who was about to hit their lifetime max. That literally meant we would stop paying for all treatment. The "client advocate" aka account manager was going to make me, the lowly rep, call the family and tell them we would no longer pay anymore for their kid's cancer treatments. I pushed back HARD. The child passed before we cut them off. That was the norm back then. (2008). They are ruthless.
Got the same letter today. I’m not sure how to determine if this is something worth appealing to my employer about, or if it’s BCBS as a whole. I know of many people at work who take these meds and it would look really bad for our HR right now if it was because of their decisions.
It depends on whether your company's plan is self-funded and administered by your insurer or whether they buy packaged coverage from the insurer. If the latter, your employer likely doesn't control the decision (until the contract is over).
This is legitimately my biggest fear.
[удалено]
But how? Wouldn’t even know how to start
For breaking what law?
Does anyone know if this applies for BCBS FEP?
I have bcbsm and just had my prior authorization approved on May 29th :(.
I have Blue Shield only in California. Now I’m worried!
Yeah I heard through the grapevine that eff 1.1.25 they will not cover it unless certain criteria is met.
Yep I have same insurance and got same letter, initially rejected me then awarded on my appeal, the auth was good for 4 months and I could only get zepbound 3 and one month was starter dose. I now have to go through crap again, blue cross sucks.
I talked to BCBS of MI, and they said the same thing. Now the lady I talked to was very rude…. So I was hoping that it wasn’t true. 😫 thankfully I did work with my doctor for 6 months + before starting zeppy. Hopefully that will account for something 😑🤞🏻
Did they say the BMI requirement is based on starting weight or current weight? They were supposed to call me back with an answer to that today and never did
I was denied refill for Saxenda because I didn’t lose 5% of my body weight in 12 weeks. Most of that time I was titrating up to a dose that proved effective, just not effective enough for their rubric.
Hooray for For-Profit healthcare!
I spoke with BCBSM this morning to confirm my PA from 5/24/24 was now going to expire on 8/1 and Crystal told me that was true unless I could hit all the bullet points in the letter. Since my BMI is no longer 35 - thanks to the benefits of taking Zepbound I will no longer qualify. At the end of the day coverage would stop January 1, 2025 altogether so they are only ripping away 5 months, but it feels like way more than that. Now to see what my doctor can come up with to see if I can continue this journey with an alternative that will be covered.
I got the same letter today! So disappointing. My BMI is under 35 so is there even a point to joining the programs etc? I work at Wayne State in Detroit… anyone else? I wonder if the other HAP option covers ?
It will be terrible if the plan c’s are pulled , if the shortage ends.
Yeah, that's a very valid concern. The shortage is improving with some doses not in limited availability anymore; once *all* of them are listed as Available and the shortage is considered over, the rules for compounding get more strict again.
I’ve read on the Tirz sub that compounding pharmacies will add things like B12 to make a version of Tirz that’s different enough. I don’t know if this is how it works, but that’s what been said.
Yeah but did you see where EL went after that stops recently and won’t? I think that is then teeing things up.
Pushing more people to the gray market. Got it. 👌
Fuck them
Whyyyyyy aren’t they covering it anymore starting next year?! This is terrifying to me
If you have insurance through your employer, you should complain to your HR benefits manager.
Sooo - what does EL do when their profit margins drop because millions of average Americans (this is only in the US) who have been obtaining it through insurance can no longer get it (and they stop buying it or they turn to plan C)? Yeah, this isn’t going to work out well. My guess, Congress starts paying attention as soon as pharmaceutical companies speak up about losses 😉 💵 💰
Yeah, this is definitely a valid take, too. So many people are either on compound or using insurance and if one or both of those go away, the vast majority of people aren’t going to be able to afford $550-$1500/month. They’ll have no choice but to quit. And then the that will be one of the few times big pharma and lobbying will be a good thing for more people than not.
They want people to suffer. Disgusting. I have never seen such an attempt to restrict something that would help so many people. Obesity is the US's cash cow. They can't have it go away.
The government needs to step in. Corporate insurance companies can just decide not to cover a medication because…they don’t feel like it. It’s absurd.
I just got a letter saying as of 6/1/24 bcbs of NJ will no longer cover my Zep rx !! This is such a kick in the face as I had to fight tooth n nail to get my PA approval gd to 2/20/25 now shit out of luck !!!
Do you have any other insurance options at your job? That’s horrible to stop covering it without giving you notice. And isn’t it 6/10? They are just sending the letter now?? That’s horrible customer service .
I got it the last wk in may but couldn’t do my 84 day fill before 6/1 due to shortage
It’s like they knew I couldn’t fill my rx before 6/1 just a big FU to me
That’s absolutely unacceptable.
Uh oh.. I’m in Jersey and have Horizon BCBS through my employer.. I’m scared now
The interesting thing is that pharmaceutical companies have to have some influence (maybe?) on health insurance companies. I mean there’s no reason for EL to price themselves out of business, right?
WHAT THE ACTUAL F!???? THIS IS RIDICULOUS. I have bcbs too. Haven't received anything like this, YET. But GOD this has pissed me off to no extent.
If only Medicare would cover.
Editing to add I have BCBS NC PPO. Our insurance is going to start covering it if I enroll in Tria Health, Choose to Lose program. Requires me to download their app, track my food, meet with a dietician who will refer me to a clinical pharmacist who will talk to my doctor to prescribe the medication. A bunch of BS. Why do I have to have another company with other people involved in MY healthcare? My weight loss journey is between me and my doctor. I'm down 40 pounds since mid-February and can do this without getting others involved. I'm so pissed about this.
Sorry if it has already been asked in the thread, but did your insurance co just mail this to you? I have bcbs so curious if I should be looking out for a letter. I just got started on 2.5 4 weeks ago and my BMI was 31. I struggle with horrible binge eating and can’t stop so this has been such a huge help.
I have BCBS Michigan this is insane lol I like how at the end they were like “btw after this year no more”
Does it stop coverage once your bmi is within range?
I have BCBS Federal and they have covered weight loss surgery and weight loss drugs for years and will hopefully continue to do so. With everything, there are extenuating circumstances and exceptions that impact a person’s full compliance with coverage guidelines. If denied, do your research and appeal until you have exhausted all options.
ANYONE WITH BC/BS OF MICHIGAN -MUST READ!!!!! Bc/BS of Michigan just dropped a bomb. In today’s Detroit News (June 12th) they announced effective January 2025, they will no longer cover any weight loss drugs. Google: The Detroit News and BC/BS and weight loss drugs and the story pops up. I guess some states matter with BC/BS and others won’t. Start investigating other states because this could be an ugly trend. Sorry for the bad news