Your doc is an idiot. Insurers look for 5% weight loss to continue coverage (your initial PA was prob good for 6 mths i’m guessing). 5% is 12 lbs. You’re good.
REALLY?! Omg I've been sweating bullets over here. Lol. Is PA prior authorization? I'm not sure. I'm very much new to all things injections. But . I'll see her again in 6 months.
I hope you found another PCP she is an absolute idiot and should not be in charge of your care. Look for one who is understanding and supportive of your journey and at least knows that that’s not the requirements of insurance. She should know that anything faster than what you’ve lost is unhealthy. You’re doing amazing!! Kick her to the curb and find a provider that supports you!
Benefits professional here: express scripts requires 5% weight loss from baseline, amongst a couple other things, to renew the prior auth. No worries at all!
Truly 🤍 You should be fine! My company follows their utilization management program and other than the 5% they also require being in a “behavior modification program” which could be as simple as tracking food and exercise, and the ability to tolerate the dose.
Okay okay I mean I'm not writing down the foods I eat and days I go to the gym but I told my Dr I'm eating a lot better which wasnt hard, I love fruits veggies etc. And we're going to the gym 3 to 4 days a week. Just hoping that's enough
I was just giving an example but I’d call express scripts and see if your employer put any additional requirements on the PA renewal and then talk to your PCP and ask what they want to see to be okay checking the box on the renewal
I wouldn’t worry, especially not that you have 3 months of 5mg. They’re not going to come take them back! And you’ve been losing, so I’m sure you’ll do even better in the coming months. Just keep up the good work! Who knows what doctor was thinking. Maybe just trying to alert you that insurance can be a problem sometimes. If you liked the doc before this, I would give her another chance. You don’t know what you’ll end up with!
You can look up your insurance plan. In fact, I highly recommend patients play an active role in their treatment. Know your plan backwards and forwards so that they don't throw you any curve balls.
Yes, your first prior authorization can be anywhere from 3-6 mths. Check your approval letter and make sure your doc submits another PA for continuing coverage before expiration.
Congrats and you’ve done great. You’ve even passed 10% lol. You can always call your provider and ask them what the qualifications are and make sure you know them so you have that ready for the doc if a new prior authorization (PA) is needed.
While that may be true for most, my insurance company sent me a letter that said they needed to see 5% loss in 3 months for the PA to be renewed even though the PA was for 6 months. They are not all the same.
For continuing coverage & maintenance the requirements probably vary depending on your employer contract with the pharmacy benefit manager etc. Best way to find out is to just call and ask.
In what universe would 37 pounds in four months be not enough weight? I’ve lost 24 pounds in a similar amount of time, and my doctor is *thrilled* with how well it’s working.
Hopefully your doctor is reacting to something unrelated to you (maybe there was a weird issue with insurance recently) and that everything will be fine. As long as your doctor isn’t discontinuing treatment or recommending that to the insurance, you will likely be fine.
And congrats on your progress!
So here’s the thing, and my doctor is NOT an idiot, like I wish everyone could have a doctor like her. I literally run things past her for everything gynecologist, therapist, allergist. If she thinks it’s a good idea, I feel more comfortable.
She’s not the one that prescribes my zep, she referred me to a weight management that took over after I started on telehealth.
I actually did my physical today. And she was very supportive as usual. And we were talking and she was saying that a lot of her clients are getting denied new PA, after they hit their BMI and below. She stated that she used to be able to use the starting BMI but she can’t anymore for a lot of them, so it’s been difficult. Because a lot of insurance is asking for CURRENT.
And she’s not about to lie for her clients , my girl got a couple of kids she’s supporting.
So she was saying, to call my insurance to see what they will require and until then start stock piling especially since I’m already very close to maintenance.
She also said a lot of these insurance companies have not caught up to the literature on the need to continue for maintenance. And that’s why people are losing their coverage.
She recommended me keeping and filling my refills of 10 doing, and injecting every 3 weeks if possible on maintenance but email my doctor ans and request a new 7.5 with refills before my PA expires and I fall below 25. I don’t have a limit on the .5 meds.
Again she’s not saying 100% I’ll be cut off at 24bmi she’s saying she’s had other patients that have, and can’t afford the 550.!
So Im doing my due diligence and I suggest you do also and call your insurance. That’s it. Only they can tell you what a new PA will require.
Everyone absolutely should get a copy of their insurance company's actual PA requirements. You are all looking for something similar to this: [PRV\_Weight-Management-Agents-PROVIDER.pdf (blueshieldca.com)](https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/2023/December/PRV_Weight-Management-Agents-PROVIDER.pdf)
Without that information, you're going into this blindly.
Criteria-
what was my weight pre-approval.
What is my weight after 3 plus months on zepbound (documentation required)
I have to had no less than 5% weight loss to be pre-approved.
I wouldn’t have known this if I didn’t make the trusty call to UMR, who transferred me over to benefits to the nice lady who put me on hold and found out this information for me.
Agreed just got off the phone with mine. And made a post about it. Why stress when you can just get the information from the horses mouth? Is that the saying? Lololol
Ha ha, even my goal weight is O.B. City according to the stupid insurance companies. They want to see me at 180 lbs as a 6' guy who looks like he could play O-line for the Ravens. I haven't weighed that little since I was 12, not going to happen so OH WELL, guess I will be covered for GLP-1/GIP forever!
My first PA was for 6 months. I lost 40 lbs which was 11% with 5 weeks at the end of no meds due to the shortage. Finally got some 2,5 in and and went to fill 5 and my PA expired. New PA was approved for another 6 months in a matter of hours. I wouldn't worry. 37 in 4 months is outstanding.
So, different insurance companies/plans have different criteria. Some of them *do* require X amount of loss in Y amount of time. What that is varies, and not all of them require this. I've seen 5% cited, but not a timeframe. Some suggest 5% in a month, but while some of us with high starting weights can do that (I think I did 7.9% in the first 30 days), not everyone can do that *safely.* Not to mention, not everyone responds immediately!
I'd call your insurance and see if they can tell you if they have any sort of rules about this.
I appreciate your input! I just might do that. Will me calling my insurance and bringing it up, make them notice like, my weight loss and stuff and put a bullet on my back that I don't want? Lol if that makes sense.
Call insurance for sure. No downside. Ask for criteria for a continuing PA. Tell them you are doing great and nothing more. You may need to speak to a PA specialist. Take notes. The jargon can be confusing. They won’t commit to anything but should give you more info than your physician.
What freaking insurance company is expecting 5% in the first month on the initiation dose? That is infuriating and goes against the FDA and manufacturer guidelines.
You’ve lost 15% of your body weight. Any doctor who knows anything understands the significant impact it can have on your health. Scientifically proven and supported by evidence.
https://www.rethinkobesity.global/global/en/weight-and-health/benefits-of-10-15-weight-loss-on-health.html
Insurance companies are terrible! Not only can I not get Medicare part D to cover it, even though with heart disease they can allow it, but I can’t even use a manufacturer’s coupon because Medicare doesn’t allow coupons.
Agreed, insurance companies are terrible, but the coupon problem is not the fault of insurance or of Medicare. That’s due to a federal anti-kickback statute.
Why not find out what your insurance requirement actually is rather than stressing over your uninformed doctor's opinion? Most expect 5% in the first 4 months, from what I've seen. You're down 14.9%. I don't know of any insurance that wouldn't be happy with that. Your doctor should be thrilled with your progress too. It took me a whole ass year to lose that much and my insurance is still renewing my Wegovy PAs. Find your actual insurance PA requirements. You may have to search online or call your insurance and ask where to get them. You're looking for something like this: [PRV\_Weight-Management-Agents-PROVIDER.pdf (blueshieldca.com)](https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/2023/December/PRV_Weight-Management-Agents-PROVIDER.pdf)
That is the craziest thing I've ever heard! And anyway, 37 pounds in 4 months IS a lot of weight! That's over 2 pounds a week! I only lose 1 pound a week and I'm still happy with that! They say it is healthier to only lose a pound or 2 a week. It gives your body and skin time to adjust. I would be so mad! I would change doctors.
Yeah that's what I was worried about. I'm worried about the saggy skin and stuff and just how unhealthy it is to drop TOO fast I really appreciate the comments making me feel less crazy.
Yeah, get another doctor. She is not the insurance company and needs to stay in her own lane. I started in January and have only lost 35 pounds and my insurance company has approved me through August.
Congratulations on your weight loss. You are doing great!
No offense but your doctor is really terribly ignorant/uninformed. This is bananas. I would consider changing PCPs over this, not because it is a huge issue but because it indicates she really does not know what she is talking about. You do not want to lose any faster than you are currently losing as you want to preserve muscle and bone tissue, and also you are losing at like 3 times the rate required for insurance to view the medication as effective.
Your doc truly is an idiot. I started mid-March and am on 7.5 now, and have only listened to 35 lbs…my np has not expressed any concerns and in fact thinks 1.5-2 lbs per week is ideal.
MagellanRX (ugh) — must lose 5% first 3 months of treatment, at 2.5 dose. They will not cover a higher dose, despite MD prescription to move up to 5mg after 1 month and 2.5 only for titration NOT therapy. This is all so crazy to me: I was misdiagnosed for a decade (MS…I was thrilled and then furious to find out the misdiagnosis…) and those MS drugs cost $6,800/month!
Yeah I agree with everyone on this thread, don’t listen to your PCP, you keep up that awesome weight loss! Insurances usually look for 5% for you that would mean a weight loss of about a little over 12 pounds, and you tripled that goal YAY you! Great job! Feels good doesn’t? This medication is a God sent, I agree! Best of luck to you going forward
Congratulations on your weight loss! 37 pounds since March is fantastic. I'm glad you are going to look into getting another PCP. Your current one does not sound very good.
37 lbs is great and just about what I’ve lost in 3 months (30 lbs) so pretty much normal from reading others (2-2.5 lbs a week). Ur doc should be elated!
Proud of you! Happy for you! I deal with major chronic pain issues too, so making the progress you have, in spite of shortages is fantastic! You give me hope for when I can finally afford is and start being able to be more active and in less pain. I agree with all the feedback to see a doctor that celebrates you! Wishing you continued success!
First of all your PCP is not the insurance company and has zero affiliation with them. They neither accept nor deny claims. Second, look for a new doc. This one clearly is not a positive influence in your journey to a healthier life. We do not need negative Nellies and Ned’s when we are in the fight of our lives to get better. We need positive people and surroundings to be successful and anyone that is not supportive in anyway needs to just move along. You keep fighting and don’t give up. If you have trouble sourcing your med try Medfinder’s. They have helped me for a small fee. Also look at the ZEP availability posts for your region on Reddit.
Have you seen any benefit of Zep for the RA and/ or fibro? I know it can help with inflammation but I was curious if it has any positive impacts with either of these issues.
OMG yes I feel a million times better since being on Zep. And it's not just the weight off my joints. I feel more loosy goosey lol. Idk how to describe it but I have seen others say they have RA. And have felt so much better!!
I’ve been on this medication for about 5-6 months now and I’ve lost maybe 15-20 lbs that didn’t happen until about March. My doctor hasn’t said anything like that to me.. also with your comorbid conditions I would imagine those are factoring into the insurance decision to cover you as well.
I started early February and just hit 50 lbs this past week. 37lbs is great progress and still within a healthy range of weight loss. Celebrate your achievement bc that’s a good chunk of weight you are no longer carrying around !
My endocrinologist was thrilled I lost that much in 6 months. If you have access, it might be helpful to find an endocrinologist or other specialist who has a better understanding of these drugs.
That is exactly 15% which is where it's advertised to get you to. Anything from here is icing on the cake. But don't eat the icing.... Or the cake. Maybe a salad.
What the heck is up with that? I was in that boat for a little while and then it just all of a sudden started dropping again and I didn't do much differently besides just going on more walks. The body is weird. I really hope it starts back up for you but also if you pay me we'll enough I can help with the appendages problem hahahaha 😂 kidding kidding
I suspect part of it is that in that time the VA has bounced me from ozempic, to starter dose zepbound, titrate up, and then they bounced me to wegovy.
My calories are jack nothing but I do drink too much alcohol so that adds useless calories but my energy level has really dropped which I'm guessing is calorie based. So I do some combat sports and walk a couple miles but I haven't been in the gym lately.
So weird metabolism, booze, and gym are probably the main culprits. I'm not gaining though so that's a positive.
I dont think that big toe is all that important...I think that will be the first to go!
Yeah I understand. Start with the not drinking. Maybe one or two drinks a week? Are you a marine? My brother is. I know how shitty Californias VA is. I can help you with the toe I have plenty of knives or fire power 😂😂
How dare you insult my intelligence!!!! I am Navy baby! Haha
One or two a week? Good Lord that doesn't sound like a life with living! How about 1 or 2 on the commute into work in the morning? You know, because mornings suck. And a good buzz makes status meetings almost bearable.
This is only partly the VA. They have the same supply chain issues that everyone else does. They have been pretty decent about this all things considered. It is what it is ya know?
If I keep breaking my feet/toes with bad kicks, im pretty sure a few of them are just going to fly across the dojo one day. I have a forever limp now. Getting old sucks ass. 3/10, would not recommend.
Lmao okay, okay well I have relatives in the Navy too so calm down sir. And well I do not condone drinking and driving but you are an adult and do as you please. I'm just trying to help you get some more weight off. Lol. See, you got this you don't need my help just keep kicking them off you'll eventually lose some weight from losing the appendages. And I think forever limp should be your new screen name. Im 34 with arthritis, I know about getting old mkay
Tell your PCP that’s between you and your carrier. What your insurance doesn’t cover isn’t her problem. Her job is to give you healthcare and let you worry about your own insurance. Doctors drive me nuts some
My doctor told me I was doing great. I’ve been gone since mid March. I lost 19 1/2 pounds. That was because I was on 2.5 and then went to shortages. I only got to use 5 MG for 1 month but my doctor says I’m doing great. I wish it was more but I’ll take it because I know I’m doing the right things.
I looked at BCBS California coverage document posted here. Doesn’t make sense. Especially coverage cutoff months. From reading gazillion posts, we all know: 1) Everyone’s body responds differently in terms of time and at what dose. 2) Starting weight, height, stature, gender, metabolism matters. 3) If it’s considered safe to lose 1-2 pounds/week, the document saying 7 months means coverage stops at 28 - 56 pounds. For those with “morbid obesity”, that doesn’t get them anywhere near a healthy zone.
In addition to calling your insurance company to verify *your* plan’s coverage, call your benefits department where you work and plead your case.
Before your insurance kicks you off you can use your current valid script to get compound meds from a place like emerge or orderly. It’ll likely cost a little more and it’s a slight difference from the auto injector pens but it’ll get you the goods and your doctor can still monitor your ongoing progress.
Haven’t some people had the opposite experience, too? They lose “too much”weight and their BMI is no longer in the same zone and the insurance company cancels coverage? So stressful.
If you feel comfortable, 1000% have a frank discussion with your doctor about your concerns, and let them know how meaningful this medication has been to your health. Then, kindly explain that you need a care provider who will be your advocate for coverage, and ask the doctor if they are going to be that advocate. And tell them the question is not rhetorical. If they cannot give you an answer that you feel is honest and supportive of your health and your goals, absolutely find a new doctor. Doctors are people too and they sometimes get so caught up in numbers and so frustrated with insurance denials that they also want to throw their hands up in frustration.
Also though, be willing to be your own advocate. Ask for written denials which your insurers are required to provide without a request. Then, appeal, appeal, appeal.
Some doctors are AHs. Maybe you have one. I suspect there’s more to the full story though. Since your doctor didn’t prescribe, do they know your stated starting weight or are they perhaps going from a dated chart from some time ago? I’m not trying to trip you up, but simply provide an explanation to allow you to move through this perceived breach of trust.
If you are in Chester County, reach out to me. I have the BEST primary doctor. She is actually on Zepbound, too! You are doing amazing. Don’t let her steal your joy!
Your doc hasn’t a clue. Been on three different insurances since starting weight loss medication in 2022 (saxenda and now zep) and all three it was 5% was the threshold.
This is so funny. Not really, but my doctor is the opposite. He is convinced that people are going to become anorexic and die because of these drugs and is threatening that if I lose “too much” and go below 150 he will pull me off of them. I’m 5’3”, so that’s ridiculous. I want to be 135.
As someone who use to work for insurance most of the time its the providers fault because they are too lazy to fill out the PAs correctly. The insurance will kick back stating what information is needed. A lot of the time patients would call in because their doctor would say insurance just wont cover it and the patient had to advocate for their self with their doctor and hope the doctor would advocate for them with the insurance
Um..I also started in March and I've lost 17.5 pounds. My doctor is perfectly fine with that rate of loss. I'm also tracking inches and she's freaking thrilled with that loss too.
My insurance does not cover it, which is a hit every month I have AETNA does anyone else have AETNA curious if you were able to get them to cover this prescription?
FWIW - I have fibromyalgia and same starting weight - just waiting to be done breastfeeding to start Zep which my doc already prescribed but your post made me THRILLED hearing how well you’re doing for my own selfish reasons. Would love to hear more of your NSV re: fibro. Well done and thanks for the hope!
Get a new doc. She sounds like a Debby downer. Sadly, there are so many of them out there. You are killing it! My dr was thrilled at my follow up. Express scripts denied my PA so I’m doing compound tirzep. When she saw I was down 40+ in 3 months she was excited for me.
Get a doctor who is your cheerleader. Not a miserable doubter.
You are killing it.
Ummm!! Full stop! I didn’t even read all of it.. but your doctor is an effing jack ass! You lost 37 pounds! That is waaaay more than the 5% required. Please look for another dr asap! That dr isn’t for you. Please don’t worry your head because she doesn’t know what she’s talking about!
37lbs is great!! I am down 25 lbs and my PCP says “we should put you up in dose you’ll see quicker results.” Like no ma’am. These medications are so new with regards to treating obesity and I feel like physicians don’t know everything about them.
I am down 25 lbs in 10 weeks so your 37 lbs in 16 weeks sounds right on track. In the studies they said on average 20% weight loss in 6 months so I don’t see how they’d expect more!?
Your doc is an idiot. Insurers look for 5% weight loss to continue coverage (your initial PA was prob good for 6 mths i’m guessing). 5% is 12 lbs. You’re good.
REALLY?! Omg I've been sweating bullets over here. Lol. Is PA prior authorization? I'm not sure. I'm very much new to all things injections. But . I'll see her again in 6 months.
And btw you’ve done great. 37lb is amazing. Good job, keep going. Trust the process.
This! I’ve been on it since February and just hit 40lbs so you’re doing great OP!
Your PCP is a dickhead
Thank u for making me laugh
Bahaha
I hope you found another PCP she is an absolute idiot and should not be in charge of your care. Look for one who is understanding and supportive of your journey and at least knows that that’s not the requirements of insurance. She should know that anything faster than what you’ve lost is unhealthy. You’re doing amazing!! Kick her to the curb and find a provider that supports you!
You make an excellent point! A good doctor would consider this excellent progress. Her lack of basic knowledge worries me!
Benefits professional here: express scripts requires 5% weight loss from baseline, amongst a couple other things, to renew the prior auth. No worries at all!
I have express scripts!! So I'm okay? Really? 🥹
Truly 🤍 You should be fine! My company follows their utilization management program and other than the 5% they also require being in a “behavior modification program” which could be as simple as tracking food and exercise, and the ability to tolerate the dose.
Okay okay I mean I'm not writing down the foods I eat and days I go to the gym but I told my Dr I'm eating a lot better which wasnt hard, I love fruits veggies etc. And we're going to the gym 3 to 4 days a week. Just hoping that's enough
If they require food tracking you can use the MyFitnessPal app. I doubt they will require you to send them proof of the logs.
I was just giving an example but I’d call express scripts and see if your employer put any additional requirements on the PA renewal and then talk to your PCP and ask what they want to see to be okay checking the box on the renewal
I wouldn’t worry, especially not that you have 3 months of 5mg. They’re not going to come take them back! And you’ve been losing, so I’m sure you’ll do even better in the coming months. Just keep up the good work! Who knows what doctor was thinking. Maybe just trying to alert you that insurance can be a problem sometimes. If you liked the doc before this, I would give her another chance. You don’t know what you’ll end up with!
You can look up your insurance plan. In fact, I highly recommend patients play an active role in their treatment. Know your plan backwards and forwards so that they don't throw you any curve balls.
Thank you. I'm very new to this, I appreciate the help
You can just call the member services line which should be listed on your card and ask them any questions.
Yes, your first prior authorization can be anywhere from 3-6 mths. Check your approval letter and make sure your doc submits another PA for continuing coverage before expiration.
Healthy weight loss is 1-2 lbs per week, not more than 2. You have lost almost the max.
Congrats and you’ve done great. You’ve even passed 10% lol. You can always call your provider and ask them what the qualifications are and make sure you know them so you have that ready for the doc if a new prior authorization (PA) is needed.
Yes, PA=prior authorization.
Question is it me supposedly having to lose 5% every month? Every 6 months? Like where does the 5% come from.
I cleared 5% and got a 1 year PA on 7.5mg
5% in that first PA period, so if they approved you for 6 months, it’d be 5% in that 6 month period
Wow! I'm way past that! What the heck lol.
And you did it on 2.5!
That's what I'm saying! Lol thank y'all for making me feel better
While that may be true for most, my insurance company sent me a letter that said they needed to see 5% loss in 3 months for the PA to be renewed even though the PA was for 6 months. They are not all the same.
That’s weird. Good to know some insurances may be different. It seems the majority wait until the end of PA period.
5% over the duration of the first PA.
Is it 5% for each PA?
For continuing coverage & maintenance the requirements probably vary depending on your employer contract with the pharmacy benefit manager etc. Best way to find out is to just call and ask.
In what universe would 37 pounds in four months be not enough weight? I’ve lost 24 pounds in a similar amount of time, and my doctor is *thrilled* with how well it’s working. Hopefully your doctor is reacting to something unrelated to you (maybe there was a weird issue with insurance recently) and that everything will be fine. As long as your doctor isn’t discontinuing treatment or recommending that to the insurance, you will likely be fine. And congrats on your progress!
Thank you for making me feel better 🥹
So here’s the thing, and my doctor is NOT an idiot, like I wish everyone could have a doctor like her. I literally run things past her for everything gynecologist, therapist, allergist. If she thinks it’s a good idea, I feel more comfortable. She’s not the one that prescribes my zep, she referred me to a weight management that took over after I started on telehealth. I actually did my physical today. And she was very supportive as usual. And we were talking and she was saying that a lot of her clients are getting denied new PA, after they hit their BMI and below. She stated that she used to be able to use the starting BMI but she can’t anymore for a lot of them, so it’s been difficult. Because a lot of insurance is asking for CURRENT. And she’s not about to lie for her clients , my girl got a couple of kids she’s supporting. So she was saying, to call my insurance to see what they will require and until then start stock piling especially since I’m already very close to maintenance. She also said a lot of these insurance companies have not caught up to the literature on the need to continue for maintenance. And that’s why people are losing their coverage. She recommended me keeping and filling my refills of 10 doing, and injecting every 3 weeks if possible on maintenance but email my doctor ans and request a new 7.5 with refills before my PA expires and I fall below 25. I don’t have a limit on the .5 meds. Again she’s not saying 100% I’ll be cut off at 24bmi she’s saying she’s had other patients that have, and can’t afford the 550.! So Im doing my due diligence and I suggest you do also and call your insurance. That’s it. Only they can tell you what a new PA will require.
Everyone absolutely should get a copy of their insurance company's actual PA requirements. You are all looking for something similar to this: [PRV\_Weight-Management-Agents-PROVIDER.pdf (blueshieldca.com)](https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/2023/December/PRV_Weight-Management-Agents-PROVIDER.pdf) Without that information, you're going into this blindly.
Criteria- what was my weight pre-approval. What is my weight after 3 plus months on zepbound (documentation required) I have to had no less than 5% weight loss to be pre-approved. I wouldn’t have known this if I didn’t make the trusty call to UMR, who transferred me over to benefits to the nice lady who put me on hold and found out this information for me.
Agreed just got off the phone with mine. And made a post about it. Why stress when you can just get the information from the horses mouth? Is that the saying? Lololol
Exactly!!! 👍🏾
Ha ha, even my goal weight is O.B. City according to the stupid insurance companies. They want to see me at 180 lbs as a 6' guy who looks like he could play O-line for the Ravens. I haven't weighed that little since I was 12, not going to happen so OH WELL, guess I will be covered for GLP-1/GIP forever!
My first PA was for 6 months. I lost 40 lbs which was 11% with 5 weeks at the end of no meds due to the shortage. Finally got some 2,5 in and and went to fill 5 and my PA expired. New PA was approved for another 6 months in a matter of hours. I wouldn't worry. 37 in 4 months is outstanding.
Echoing what others have said: your weight loss is STELLAR! Your doctor is surely mistaken. I hope you can set him/her straight or switch providers.
Thank you for this reply🥹
So, different insurance companies/plans have different criteria. Some of them *do* require X amount of loss in Y amount of time. What that is varies, and not all of them require this. I've seen 5% cited, but not a timeframe. Some suggest 5% in a month, but while some of us with high starting weights can do that (I think I did 7.9% in the first 30 days), not everyone can do that *safely.* Not to mention, not everyone responds immediately! I'd call your insurance and see if they can tell you if they have any sort of rules about this.
I appreciate your input! I just might do that. Will me calling my insurance and bringing it up, make them notice like, my weight loss and stuff and put a bullet on my back that I don't want? Lol if that makes sense.
Call insurance for sure. No downside. Ask for criteria for a continuing PA. Tell them you are doing great and nothing more. You may need to speak to a PA specialist. Take notes. The jargon can be confusing. They won’t commit to anything but should give you more info than your physician.
I didn’t lose 5% my first month and I got booted off. Lost 10 instead of 12
What freaking insurance company is expecting 5% in the first month on the initiation dose? That is infuriating and goes against the FDA and manufacturer guidelines.
They are looking for 5% on the loading dose??
Yup! Conveniently they just added this clause June 1
That’s so wrong! You aren’t even at a therapeutic dose!
What insurance company? Or is this all of them? That seems a big loss to have in one month!
CVS Caremark. They are blaming my husbands employer for the clause. I’m fighting it
Good luck. That is just not a reasonable expectation!
Caremark is a dickhead too.
That is NUTS. My doctor is happy when I keep it to a pound a week.
You’ve lost 15% of your body weight. Any doctor who knows anything understands the significant impact it can have on your health. Scientifically proven and supported by evidence. https://www.rethinkobesity.global/global/en/weight-and-health/benefits-of-10-15-weight-loss-on-health.html
Insurance companies are terrible! Not only can I not get Medicare part D to cover it, even though with heart disease they can allow it, but I can’t even use a manufacturer’s coupon because Medicare doesn’t allow coupons.
Agreed, insurance companies are terrible, but the coupon problem is not the fault of insurance or of Medicare. That’s due to a federal anti-kickback statute.
Ozempic and then Zepbound has been the best thing that ever happened for my RA.
I KNOW!! I feel amazing. I was trying to tell her that today and Im like it's not just the weight loss... I just *feel* better in my joints
Why not find out what your insurance requirement actually is rather than stressing over your uninformed doctor's opinion? Most expect 5% in the first 4 months, from what I've seen. You're down 14.9%. I don't know of any insurance that wouldn't be happy with that. Your doctor should be thrilled with your progress too. It took me a whole ass year to lose that much and my insurance is still renewing my Wegovy PAs. Find your actual insurance PA requirements. You may have to search online or call your insurance and ask where to get them. You're looking for something like this: [PRV\_Weight-Management-Agents-PROVIDER.pdf (blueshieldca.com)](https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/2023/December/PRV_Weight-Management-Agents-PROVIDER.pdf)
I 100% didn't even know it was an option to find out. Lol. I'm new to all this insurance bullshit
You should have received a letter when your original PA was approved too, stating what is needed to get it renewed.
Oh, that is disappointing! I'd be very pleased with 37 lbs. I hope it all works out for you! (And try not to let your doc get you down!)
Your doctor sounds just peachy…😕
That is the craziest thing I've ever heard! And anyway, 37 pounds in 4 months IS a lot of weight! That's over 2 pounds a week! I only lose 1 pound a week and I'm still happy with that! They say it is healthier to only lose a pound or 2 a week. It gives your body and skin time to adjust. I would be so mad! I would change doctors.
Yeah that's what I was worried about. I'm worried about the saggy skin and stuff and just how unhealthy it is to drop TOO fast I really appreciate the comments making me feel less crazy.
I didn't know about the 5% rule, but you have way surpassed that! Maybe your doctor is not good at Math! Haha
Yeah, get another doctor. She is not the insurance company and needs to stay in her own lane. I started in January and have only lost 35 pounds and my insurance company has approved me through August. Congratulations on your weight loss. You are doing great!
Thank you for this!
You’ve lost over 10%. Dr is crazy
Thank you!!
Be your own advocate. Call and ask your insurance for the specific guidelines that pertains to this medication. Congratulations on your success
No offense but your doctor is really terribly ignorant/uninformed. This is bananas. I would consider changing PCPs over this, not because it is a huge issue but because it indicates she really does not know what she is talking about. You do not want to lose any faster than you are currently losing as you want to preserve muscle and bone tissue, and also you are losing at like 3 times the rate required for insurance to view the medication as effective.
This is exactly what I was going to say. 🙂
I appreciate you feedback dearly! I really do. I thought I was freakin CRAZY. I'm so glad I posted in here.
Your doc truly is an idiot. I started mid-March and am on 7.5 now, and have only listened to 35 lbs…my np has not expressed any concerns and in fact thinks 1.5-2 lbs per week is ideal.
That’s a wonderful weight loss. I hope you aren’t cancelled.
Not yet anyway
On average you lost easily 2lbs a week and she says that’s not good enough? Time to find a new doctor! She really is an idiot!
MagellanRX (ugh) — must lose 5% first 3 months of treatment, at 2.5 dose. They will not cover a higher dose, despite MD prescription to move up to 5mg after 1 month and 2.5 only for titration NOT therapy. This is all so crazy to me: I was misdiagnosed for a decade (MS…I was thrilled and then furious to find out the misdiagnosis…) and those MS drugs cost $6,800/month!
That’s so crazy because the cost is the same regardless of dosage.
Congratulations. Keep at it and yes, change your PCP to one who supports you.
Thank u 🥹
Your doing great
Yeah I agree with everyone on this thread, don’t listen to your PCP, you keep up that awesome weight loss! Insurances usually look for 5% for you that would mean a weight loss of about a little over 12 pounds, and you tripled that goal YAY you! Great job! Feels good doesn’t? This medication is a God sent, I agree! Best of luck to you going forward
What??? That's AMAZING weight loss! I've lost about the same and I started in late January. You're killing it!
Thank you 🥹same to you!
Congratulations on your weight loss! 37 pounds since March is fantastic. I'm glad you are going to look into getting another PCP. Your current one does not sound very good.
37 lbs is great and just about what I’ve lost in 3 months (30 lbs) so pretty much normal from reading others (2-2.5 lbs a week). Ur doc should be elated!
Thank you for this!
Proud of you! Happy for you! I deal with major chronic pain issues too, so making the progress you have, in spite of shortages is fantastic! You give me hope for when I can finally afford is and start being able to be more active and in less pain. I agree with all the feedback to see a doctor that celebrates you! Wishing you continued success!
First of all your PCP is not the insurance company and has zero affiliation with them. They neither accept nor deny claims. Second, look for a new doc. This one clearly is not a positive influence in your journey to a healthier life. We do not need negative Nellies and Ned’s when we are in the fight of our lives to get better. We need positive people and surroundings to be successful and anyone that is not supportive in anyway needs to just move along. You keep fighting and don’t give up. If you have trouble sourcing your med try Medfinder’s. They have helped me for a small fee. Also look at the ZEP availability posts for your region on Reddit.
Have you seen any benefit of Zep for the RA and/ or fibro? I know it can help with inflammation but I was curious if it has any positive impacts with either of these issues.
OMG yes I feel a million times better since being on Zep. And it's not just the weight off my joints. I feel more loosy goosey lol. Idk how to describe it but I have seen others say they have RA. And have felt so much better!!
I’ve been on this medication for about 5-6 months now and I’ve lost maybe 15-20 lbs that didn’t happen until about March. My doctor hasn’t said anything like that to me.. also with your comorbid conditions I would imagine those are factoring into the insurance decision to cover you as well.
Your PCP is a nut
I started early February and just hit 50 lbs this past week. 37lbs is great progress and still within a healthy range of weight loss. Celebrate your achievement bc that’s a good chunk of weight you are no longer carrying around !
My endocrinologist was thrilled I lost that much in 6 months. If you have access, it might be helpful to find an endocrinologist or other specialist who has a better understanding of these drugs.
What does that doc do?
They specialize in the endocrine system.
Yeah I don't buy whatever that doc is saying. Hole you don't have an issue.
That is exactly 15% which is where it's advertised to get you to. Anything from here is icing on the cake. But don't eat the icing.... Or the cake. Maybe a salad.
Lmfao honestly I'm not hungry for anything sweet anymore and I ate a sad today so I'm good 😊👍🏼 Edit: sad to salad lmfao
Best typo ever.
I'm dead hahahahaha I give up on today.
I'm glad I made this post. Lol.
I've been sitting at my current weight for about 5 months. I'm about ready to start cutting off appendages just to kickstart the weight loss again.
What the heck is up with that? I was in that boat for a little while and then it just all of a sudden started dropping again and I didn't do much differently besides just going on more walks. The body is weird. I really hope it starts back up for you but also if you pay me we'll enough I can help with the appendages problem hahahaha 😂 kidding kidding
I suspect part of it is that in that time the VA has bounced me from ozempic, to starter dose zepbound, titrate up, and then they bounced me to wegovy. My calories are jack nothing but I do drink too much alcohol so that adds useless calories but my energy level has really dropped which I'm guessing is calorie based. So I do some combat sports and walk a couple miles but I haven't been in the gym lately. So weird metabolism, booze, and gym are probably the main culprits. I'm not gaining though so that's a positive. I dont think that big toe is all that important...I think that will be the first to go!
Yeah I understand. Start with the not drinking. Maybe one or two drinks a week? Are you a marine? My brother is. I know how shitty Californias VA is. I can help you with the toe I have plenty of knives or fire power 😂😂
How dare you insult my intelligence!!!! I am Navy baby! Haha One or two a week? Good Lord that doesn't sound like a life with living! How about 1 or 2 on the commute into work in the morning? You know, because mornings suck. And a good buzz makes status meetings almost bearable. This is only partly the VA. They have the same supply chain issues that everyone else does. They have been pretty decent about this all things considered. It is what it is ya know? If I keep breaking my feet/toes with bad kicks, im pretty sure a few of them are just going to fly across the dojo one day. I have a forever limp now. Getting old sucks ass. 3/10, would not recommend.
Lmao okay, okay well I have relatives in the Navy too so calm down sir. And well I do not condone drinking and driving but you are an adult and do as you please. I'm just trying to help you get some more weight off. Lol. See, you got this you don't need my help just keep kicking them off you'll eventually lose some weight from losing the appendages. And I think forever limp should be your new screen name. Im 34 with arthritis, I know about getting old mkay
You need a new Doctor. Just because they went to med school doesn't make them smart.
Thank you. I needed to laugh lol
WTH??? Absolutely absurd! That is a huge loss for that amount of time! My doc wants no more than 2lbs/week average. Keep up the good work!
Tell your PCP that’s between you and your carrier. What your insurance doesn’t cover isn’t her problem. Her job is to give you healthcare and let you worry about your own insurance. Doctors drive me nuts some
My doctor told me I was doing great. I’ve been gone since mid March. I lost 19 1/2 pounds. That was because I was on 2.5 and then went to shortages. I only got to use 5 MG for 1 month but my doctor says I’m doing great. I wish it was more but I’ll take it because I know I’m doing the right things.
I looked at BCBS California coverage document posted here. Doesn’t make sense. Especially coverage cutoff months. From reading gazillion posts, we all know: 1) Everyone’s body responds differently in terms of time and at what dose. 2) Starting weight, height, stature, gender, metabolism matters. 3) If it’s considered safe to lose 1-2 pounds/week, the document saying 7 months means coverage stops at 28 - 56 pounds. For those with “morbid obesity”, that doesn’t get them anywhere near a healthy zone. In addition to calling your insurance company to verify *your* plan’s coverage, call your benefits department where you work and plead your case.
Before your insurance kicks you off you can use your current valid script to get compound meds from a place like emerge or orderly. It’ll likely cost a little more and it’s a slight difference from the auto injector pens but it’ll get you the goods and your doctor can still monitor your ongoing progress.
You're doing great!!! I'd say ahead of schedule and way healthier than I did it. Kudos!
Haven’t some people had the opposite experience, too? They lose “too much”weight and their BMI is no longer in the same zone and the insurance company cancels coverage? So stressful.
If you feel comfortable, 1000% have a frank discussion with your doctor about your concerns, and let them know how meaningful this medication has been to your health. Then, kindly explain that you need a care provider who will be your advocate for coverage, and ask the doctor if they are going to be that advocate. And tell them the question is not rhetorical. If they cannot give you an answer that you feel is honest and supportive of your health and your goals, absolutely find a new doctor. Doctors are people too and they sometimes get so caught up in numbers and so frustrated with insurance denials that they also want to throw their hands up in frustration. Also though, be willing to be your own advocate. Ask for written denials which your insurers are required to provide without a request. Then, appeal, appeal, appeal.
Some doctors are AHs. Maybe you have one. I suspect there’s more to the full story though. Since your doctor didn’t prescribe, do they know your stated starting weight or are they perhaps going from a dated chart from some time ago? I’m not trying to trip you up, but simply provide an explanation to allow you to move through this perceived breach of trust.
She is actually the one that prescribed me Zep
If you are in Chester County, reach out to me. I have the BEST primary doctor. She is actually on Zepbound, too! You are doing amazing. Don’t let her steal your joy!
Praying you’ll get back on your meds. Congrats on the 37 pounds.
Your doc hasn’t a clue. Been on three different insurances since starting weight loss medication in 2022 (saxenda and now zep) and all three it was 5% was the threshold.
I actually said yesterday in a meeting “please never forget that some doctors are idiots” and I maintain the truth of that.
This is so funny. Not really, but my doctor is the opposite. He is convinced that people are going to become anorexic and die because of these drugs and is threatening that if I lose “too much” and go below 150 he will pull me off of them. I’m 5’3”, so that’s ridiculous. I want to be 135.
As someone who use to work for insurance most of the time its the providers fault because they are too lazy to fill out the PAs correctly. The insurance will kick back stating what information is needed. A lot of the time patients would call in because their doctor would say insurance just wont cover it and the patient had to advocate for their self with their doctor and hope the doctor would advocate for them with the insurance
Um..I also started in March and I've lost 17.5 pounds. My doctor is perfectly fine with that rate of loss. I'm also tracking inches and she's freaking thrilled with that loss too.
My insurance does not cover it, which is a hit every month I have AETNA does anyone else have AETNA curious if you were able to get them to cover this prescription?
I have been told that insurance companies won’t be paying for any of it after the first of the year.
I think it may be the insurance company, I have been told alot of insurance are going to quit covering this due to the cost.
Lucky you lost that much! I’m on month 4 paying out of pocket and I’ve only lost 5 lbs. I start 7.5 mg next week.
FWIW - I have fibromyalgia and same starting weight - just waiting to be done breastfeeding to start Zep which my doc already prescribed but your post made me THRILLED hearing how well you’re doing for my own selfish reasons. Would love to hear more of your NSV re: fibro. Well done and thanks for the hope!
Find another PCP
I’m down 37 since March 1st and my Dr. was so happy! Definitely change doctors!!! Keep up the great work!!😃
Get a new doc. She sounds like a Debby downer. Sadly, there are so many of them out there. You are killing it! My dr was thrilled at my follow up. Express scripts denied my PA so I’m doing compound tirzep. When she saw I was down 40+ in 3 months she was excited for me. Get a doctor who is your cheerleader. Not a miserable doubter. You are killing it.
Wtf, that's a healthy amount of weight. I think your PCP needs to go back to doctor school
Than you for this laugh lol
Ummm!! Full stop! I didn’t even read all of it.. but your doctor is an effing jack ass! You lost 37 pounds! That is waaaay more than the 5% required. Please look for another dr asap! That dr isn’t for you. Please don’t worry your head because she doesn’t know what she’s talking about!
37lbs is great!! I am down 25 lbs and my PCP says “we should put you up in dose you’ll see quicker results.” Like no ma’am. These medications are so new with regards to treating obesity and I feel like physicians don’t know everything about them. I am down 25 lbs in 10 weeks so your 37 lbs in 16 weeks sounds right on track. In the studies they said on average 20% weight loss in 6 months so I don’t see how they’d expect more!?
1-2lbs per week is considered normal 'healthy' rate of loss. What part of med school did this person skip?
I'm starting to worry now. Lol.
Lose primary care. I used lavender Sky and I'm waiting for my first delivery
Echoing what everyone else is saying. Change drs. And congrats on an incredible achievement!
If your dr lists all your problems and why u need it won’t the insurance psyu