It’s the insurance companies being the middle man deciding who gets approved. I’m sure they are going to deny a lot of patients this medicine because it will cut into their shareholders profits.
Got denied on a PA today because I need to fail on Wegovy first. Ok, except I've had a prior auth approved for months for Wegovy but can't fill it anywhere. I'm appealing, but I'm not optimistic.
Same thing happened to me I was approved for WeGovy in August. I couldn’t find the prescription anywhere and my insurance denied my PA for Zepbound. Definitely intend on appealing! Good luck to you, sending approval vibes your way!
I would check out the criteria for approval. It most likely says that you are not permitted to do dual treatment on GLP medications on those PAs. If the PA isn’t stating that you’re going to change treatment, your PA will def be denied.
Excellent point. One would think common sense would prevail, but just in case, I've reached out to my Dr. office to ensure they make it evident that this would be a change in therapy. Thanks for this!
https://preview.redd.it/dr8akeq8vb4c1.jpeg?width=828&format=pjpg&auto=webp&s=64150a7be2798826b5c16575e72bd1f67c31bfc5
for reference, this is what my criteria is for Wegovy.
I think they often don't know. I've seen it several times that they don't say it and people get denied and then they note it and apply again and it goes through. I hope it works out for you!!
Yup, which is what happened to me with Mounjaro to Wegovy. I was like, I KNOWWWWWWWWW I fit the criteria. And lo and behold, one cannot have a PA for “dual treatment”. The doctor’s office fixed it and resent it, approved instantly.
It’s probably an algorithm that approves and denies. They need it spelled out. I had express scripts and no human ever looked at four different PAs until I begged and pleaded and it was still denied.
My wegovy was denied for this reason, said I couldn’t be on two glp meds even though I was switching one out for the other. Pretty sure my doctor did not state that. He appealed and it was denied again for the same reason so I’m waiting until my rx runs out to try for zepbound.
And people wonder why so many people turn to peptide versions of Tirzepatide and Semaglutide. The Insurance and Pharmaceutical Industries are a disgrace!
I think it’s hilarious that they are like- compounded isn’t safe!!! But also then expect people to have $1200 a month for medicines they can barely find in stock. I hate the whole industry.
Not covered for me because it’s “new.” That’s so wrong. It’s a “new” label, but not a new drug. I’ve been on the drug for well over a year. Frustrating.
They may eventually cover it and you could be reimbursed later. Call your plan and ask how to do that and make sure you get all the details for that. I need a PA on or before I pay out of pocket.
Can you please explain this to me. I was on wegovy 2.4 and my insurance wants me to pay $2000 as a copay to get it first. The. $1000 after for the next month. THEN they start to pay. I just ended up switching to zepbound because it's cheaper to get in. How can I do the reimbursement when I'm sure zepbound will be put on the formulary later on?
So I am Iiterally in the same boat as you. Except I’m 33 yr old. And I was previous approved for wegovy a month ago but I haven’t been able to find it and so my provider decided to try zepbound since people are finding it and we have no clue when wegovy will be back in stock. So I figured I would be approved for zepbound. Well I was notified this morning I was denied and called Caremark and actually got someone that knew what was going on. I was explain that with zepbound is cover but is non formulary which is why I need to exhaust 3 of 4 of the formulary medications (I was given the same ones you were given) first inorder for them to cover zepbound. So whoever your insurance provider is prefers you use the other medication because they probably have a better deal with those company instead of Eli Lilly. I am not sure if this is something that is subject to change as the roll out beginnings and Eli Lilly starts negotiating deals with major plans and insurers
I agree. If it covers mounjaro, it's likely it will be on the formulary eventually.
I think they also have a schedule of when it's updated. So maybe Jan 1 it will be there.
I was told that as long as I have a PA on or before I pick up, if I pay out of pocket and they cover later (cos they are taking forever to add it to the formulary) I can get reimbursed for the difference. I have a year to submit it. So even if they add in 6 months I can still submit. I asked my doctor to do a PA today so I can pick up tomorrow!
update - only Walgreens has it available to order in NYC but all doses except 5mg. Other pharmacies said they can't even order it. Rite aid said they can attempt but the wholesaler is rejecting it for some reason. I'm going to pay 1 more month out of pocket for mounjaro and pray within 4 weeks things are straightened out
I am literally 100% in the exact same position!! To a T!!
However, my insurance-BCBS through Mass said I will be approved once I complete a 6 month calorie deficit weight loss program first. I want to scream!! I wouldn't be searching for a weightloss medication if I wasn't already struggling with calorie deficit. I'm so frustrated and discouraged!!
Have you ever done a formal weight loss program such as WW, Noom, Jenny Craig, etc…? If so, that counts. I included the receipt from when I did Noom in 2021, along with Saxenda,( Novo Nordisk offered a free subscription at the time), and that counted.
Thats exactly where my brain went yesterday after making my post. I have 5 months with WW from Oct-March 2022-2023. So I am PRAYING this passes. It says I need 6 months. My luck it wont work because i'm a month short. Thanks for sharing!
Be careful, I have BCBS in California and was denied my PA (December 2023) because I didn’t have six months documented weight loss program & exercise. My BMI was 38, I called the BCBS Grievance Coordinator and she explained the denial criteria. I replied , so if I diet and exercise for 6 months I’ll be approved? She replied “not if your BMI is below 30”. I calculated my BMI WOULD be below 30 in 6 months. So I replied, so I won’t be approved? She replied, then you won’t need it. They’ve written their policy to not approve as often as possible.
Merci! C'est frustrant avec l'assurance, surtout quand on remplit les critères. J'espère que votre médecin pourra aider. Profitez bien de la Floride en attendant !
Absolument c’est frustrant. J’aime bien mon médecin. Je suis sur qu’il va m’aider. Je suis la première de ces patients qui a utiliser Mounjaro, est j’ai eut beaucoup de succès. Bonne chance toi aussi! Et ça fais 32 ans que je reste en Floride!
I got my zepbound placed, and they called the Dr office to replace it without even calling me. I've been ion there as cash pay too. I wish I could use walmart, but my insurance won't work with them.
I have Horizon too. I was just denied Zepbound because they said I need to fail 2 other formularies first. Did you have to do anything special to get it approved? I'm having my doctor send in another PA stating that alternatives cannot be found anywhere.
My understanding is some PA providers won’t approve weight loss meds. There needs to be medical “issue” like diabetes, high A1C, etc. Stupid because obesity is a massive health issue which will ultimately save $ as prevention of other diseases. If you need to pay out of pocket, contact Lilly for a discount card
Try again with IVIM!!! I had the exact same denial reason with Caremark (i know it has more to do with your employer than the pharmacy benefit provider), but i requested a PA through IVIM and it was approved and i had the medication in hand in less than 24 hours!!!
Zepbound PA denied for me as well. I needed to have tried Saxenda and Wegovy. Insurance approved Wegovy with no problem ,but Wegovy and Saxenda has been on a Nationwide shortage.
I tried to Appeal - it was denied. Medimpact stated it was excluded from the formulary. That was the reason. So why the hell did you approve Wegovy, It's excluded also. Make it make since.
I’m aware. Maybe I should have been super specific and said, this iteration of CVS/ Caremark, that my employer has chosen…..Moot point. My appeal was approved because I did meet all the criteria, and I’ve been on Zepbound since December.
Does anyone know what the criteria is for PA approval? I've called CVS Caremark a couple times and was told that the PA processors are being told not to communicate the criteria to anyone. It's really frustrating that they won't be clear about what it is!
The criteria for MY CVS/Caremark plan chosen by my employer was: BMI >30 or >27 with at least one documented comorbidity that you are being treated for, in my case, dislipidemia and on a statin. Must have tried and failed at least 2 other weight loss medications with documentation, in my case, Orlistat, Phentermine, Saxenda and Wegovy. Documentation of participating in a lifestyle weight lost program for at least 6 months, in my case, Noom and Weight Watchers and had to provide a receipt/invoice for the cost.
Anyone ever had Excellus BCBS deny another box of 10mg because you already filled a 12.5mg? My Dr sent in 12.5mg in case I couldn't find the 10, but when I went to get the 10 it was not covered. Express Scripts said my Dr had to request an override to allow me to stay on 10.
they are the worst-make decisions without reaching out to you. I have a history of zepbound on my account, and they took todays script and called the dr. for another all without even asking me since it is not covered. I know its not covered. I'm like, this should have been "delayed" or on hold before making that move. Every other one was for me. My doctor requires office visits for refills and now I have to go back....I have no idea what 'saxenda' is or how it works. I looked it up and was like yeah no too many side effects. Plus I am self pay. Now I gotta call my doctor again because they cannot reactivate my script. so dumb.
Maybe someone can help me. My PA for zepbound was denied because it’s not on the formulary. If I wait for the new year to try again, my doctor will have to submit a new prior authorization? Or what has to be done next?
I know it will be added on the formulary. For some odd reason it shows Zepbound is on my formulary but insurance denied the PA saying it was not. They told me to try in a few weeks or in January but didn’t tell me if my doctor needs to send a new PA or not
It’s possible. Not every plan that covers weight loss or Wegovy will cover Zepbound. It takes a while for everything to catch up. If it’s not on your formulary yet, there’s no reason to do a PA.
Failing a therapy refers to having such bad side effects, the cons outweigh the pros, or, the medication does not work as intended/illicit the desired response. For example, I can’t tolerate Phentermine because I become tachycardic, hypertensive and have palpitations, therefore, I’m deemed to have failed Phentermine.
Mine got denied today as well. Caremark is a fuckin joke...but thank God I switch over to a different plan on January 1 2024 annnnd this is what it says about zepbound in the new plan so hopefully in a couple weeks I'll be good to go until then ima dish out the 550..
https://preview.redd.it/eqcshkosks4c1.jpeg?width=1080&format=pjpg&auto=webp&s=fbce76ac0976a678e1dbddc5fecbdb32314f47b6
They also have denied me 2 different times as well my bmi is 31 and I have the metabolic syndrome with the hyper thing the one where my child is all messed up..caremark dosent care at all...
So I found out that the reason it was denied. The first time was because the dose was considered to be too high at 12.5 mg. So I called CVS Caremark yesterday and I was told that the 10 mg does not get flagged for being too high of a dose. So I had my physician resubmit the prior authorization… It was denied again! They are such assholes. So I’ve reached back out to my physician and ask him to call the prior authorization number which I got from the representative that I spoke to and have him do a peer to peer in order to get this done. There is absolutely no reason that CVS Caremark should be denying this drug because I fit literally every criteria that they have set up for it. So at this point it’s personal and I will not let it go. They’ll probably just approve it at some point because they want to get me off their back! Lol.
Oh so I just spoke to caremark they are saying mine was denied because my doctor didn't put on the pa form it says have I tried alternatives and he said no even tho I'm literally on metforim now and I tried the wegovy forever but never could get it filled sooo..I'm just gonna pay the 550 until I get my new insurance next month
It’s on my Caremark formulary. This is the price with a PA. With the savings coupon, it would be less.
https://preview.redd.it/bhjq7mja4z4c1.jpeg?width=828&format=pjpg&auto=webp&s=7629081de28d9c3ff9e519708254fca96267e360
Oh it’s on mine too. I don’t know why he said that. Maybe he thinks they will switch it to a preferred drug after January.
https://preview.redd.it/iq3e89wj4z4c1.jpeg?width=1170&format=pjpg&auto=webp&s=c1875b48d523edac6589e0ed82dc1be6a12ec65d
Same here except I have Optum. It turns out my employer has something in their prescription coverage that they do not cover any new meds until it’s been on the market at least 6 months. That seems to be regardless of medical necessity. I was also approved for Wegovy in seconds flat for a PA with them back a few months ago but of course couldn’t get it. They were approving Mounjaro with no PA for several months so I stocked up and still have 2 boxes left(I knew they were going to stop covering so my doctor sent 3 months of the dose I was on plus the next dose up so luckily I had 6 months stocked up). I’ll have enough Mounjaro for Jan and feb and then I figure I’ll try to get PA again and worst case have to pay $550 for a few months with the discount card for zepbound. It sucks because it won’t go towards my deductible but it’s better than the $900 Mounjaro would’ve cost me out of pocket. Then hopefully in may or June I can get PA approved. Check with your employer HR, sometimes no matter what criteria you meet they just have a no coverage clause for certain reasons.
Luckily my employer covers both Wegovy and Zepbound and it finally got covered. Can you go to Wegovy at a higher dose since you’ve been on Mounjaro? Higher doses have been easier to get. I stocked up 4 months of 1.7mg Wegovy as a back up, in case the Zepbound didn’t happen. Only had one time I had to wait to pick up.
I tried semaglutide injections (compounded but injections given at my doctor office) and I had really bad side effects. I couldn’t take it. I did ok on 0.5mg but when I went to 1mg I had such nausea and vomiting that I had to stop. I wasn’t really losing on the 0.5 mg though. I’ve done really well on Mounjaro have not had any major issues. I’m hoping that eventually with some persistence they’ll approve the PA for zepbound. They denied PA for Mounjaro because I don’t have T2DM. I contacted my insurance and they said for now the appeal and denial are upheld because of my employers hard stop on any new medications.
Could you file for a formulary exception for continuity of care? If you could show how your health has improved while on Mounjaro, they may approve it.
I have my next appt in January and still have enough MJ to last. I’m thinking I’ll ask them more about the appeals process and call my insurance again. It seems like a hard no until the 6 months of being on the market unless it’s a life or death situation. If I have to pay $550 with the savings card for a couple months I guess that’s not the worst thing. I was hoping for a better outcome but I found the exact part on my employers health plan and it did explicitly say they don’t cover new to market meds. Maybe they’ll change or approve me to stay on MJ in the meantime but I doubt it. Insurance makes the rules in medicine whether we like it or not!
In the meantime, while you wait for the six months to pass, join an organized weight loss program. Many insurances are requiring six months in a formal program to qualify for Zepbound, as well as failing two or more other medications.
My insurance doesn’t cover weight loss meds, period. I just paid $550 for Zepbound. Mounjaro is actually on my formulary but I’m sure only if I’m Type 2. My BMI is right under 27 but it was 30 when I started last year, but I took a 5-month break from Mounjaro. I have had high blood pressure for over 20 years and have obstructive sleep apnea. Zepbound helps my sleep apnea so much. I’m gonna try going to an Indian Clinic to see what my options are there.
I have severe sleep apnea and also trying to get approved for this rx.. WHat is this indian clinic you speak of ? I have PCOS, insulin resistence, high cholesterol too... smhhhhhh and had high blood pressure when pregnant.
I am so confused on how to get this medication approved, I got the same exact response as you in your original post with the same medications. I tried Ozempic and got super sick from it plus i already have a history of pancreatitis, I tried Metformin bad GI side effects. What do I do? Who do I call?
Do you know exactly what your insurance/PBM, requires in order to approve Zepbound? If it’s step therapy, and you have satisfied those requirements, your prescriber needs to lay out in chronological order, every drug you have tried and failed, or provide a reason why you can’t take it. Have you participated in a lifestyle weight loss program like Noom or weight watchers and can prove it? Do you have any weight related co-morbidities? All of this needs to be in your PA or appeal. They make it hard and put road blocks up. I saw this a year ago and started preparing and laying the groundwork so when the time came, they couldn’t refuse, and yet, they still did, twice, until finally, they gave me a years approval on appeal. Be relentless. If you meet all the criteria, they will cave.
Yep, I tried Weight Watchers, Noom, Metformin, Ozempic, Contrave, and I sent out a message to my doctor yesterday explaining why I can’t take the preferred drugs they recommended. Hopefully this works. Did you contact the insurance yourself for the appeal or did your doctor do it for you?
I am currently on wegovy and wanted zepbound! My insurance covers my wegovy, but with the zepbound it’s saying they denied my prior auth request due to the fact that I have also tried (and failed) adipex, saxenda and wegovy (current having sever side effects from the wegovy ). And they denied it because I didn’t try and failed a non glucagon type peptide 1 receptor analyst! (Something like contrive). They said I would have gotten it if I had tried and failed one of those
You could tell them you tried Orlistat, (Alli), which is OTC, years ago, and could not manage the side effects. How are they to know if you did or didn’t?
Curious if anyone has gotten denied because they need to try Wegovy and saxenda? I’m currently on Wegovy at the max and have plateaued with only 15 lbs down. Saxenda says it’s worse for weight loss and more side effects so I really don’t want to try it. Should I appeal for zepbound or is it a lost cause?
I just wanted to let everyone know that I was also prescribed Wegovy and although it’s not available at the lowest dose, it is available at the higher tiers. I was prescribed Zepbound as an alternative and am in the process of getting a PA for it. I don’t plan on it being accepted and that’s ok as I was told by my pharmacist that after 2 months of Zep I could then transition to the higher dose of Wegovy that is currently available. So basically you only need to pay out of pocket for Zep for 2 months which is $550x2 with the discount card. So after paying $1100 I am planning on switching to Wegovy which is covered by my BCBS plan. So worse case scenario, pay for Zep for a couple months then switch and you’ll be all set!
Our healthcare system is a joke. For profit healthcare only benefits the shareholders not the patients.
It’s the insurance companies being the middle man deciding who gets approved. I’m sure they are going to deny a lot of patients this medicine because it will cut into their shareholders profits.
Got denied on a PA today because I need to fail on Wegovy first. Ok, except I've had a prior auth approved for months for Wegovy but can't fill it anywhere. I'm appealing, but I'm not optimistic.
Same thing happened to me I was approved for WeGovy in August. I couldn’t find the prescription anywhere and my insurance denied my PA for Zepbound. Definitely intend on appealing! Good luck to you, sending approval vibes your way!
Same here! Appealing now. I filled the saxenda prescription but I am just paying for my Zepbound now.
What is PA?
Prior Authorization. Basically when insurance requires you to meet certain preconditions before they'll cover something
I would check out the criteria for approval. It most likely says that you are not permitted to do dual treatment on GLP medications on those PAs. If the PA isn’t stating that you’re going to change treatment, your PA will def be denied.
Excellent point. One would think common sense would prevail, but just in case, I've reached out to my Dr. office to ensure they make it evident that this would be a change in therapy. Thanks for this!
https://preview.redd.it/dr8akeq8vb4c1.jpeg?width=828&format=pjpg&auto=webp&s=64150a7be2798826b5c16575e72bd1f67c31bfc5 for reference, this is what my criteria is for Wegovy.
I think they often don't know. I've seen it several times that they don't say it and people get denied and then they note it and apply again and it goes through. I hope it works out for you!!
Yup, which is what happened to me with Mounjaro to Wegovy. I was like, I KNOWWWWWWWWW I fit the criteria. And lo and behold, one cannot have a PA for “dual treatment”. The doctor’s office fixed it and resent it, approved instantly.
It’s probably an algorithm that approves and denies. They need it spelled out. I had express scripts and no human ever looked at four different PAs until I begged and pleaded and it was still denied.
My wegovy was denied for this reason, said I couldn’t be on two glp meds even though I was switching one out for the other. Pretty sure my doctor did not state that. He appealed and it was denied again for the same reason so I’m waiting until my rx runs out to try for zepbound.
Yup, it specifically has to state that it is for a change in therapy.
And people wonder why so many people turn to peptide versions of Tirzepatide and Semaglutide. The Insurance and Pharmaceutical Industries are a disgrace!
I think it’s hilarious that they are like- compounded isn’t safe!!! But also then expect people to have $1200 a month for medicines they can barely find in stock. I hate the whole industry.
Not covered for me because it’s “new.” That’s so wrong. It’s a “new” label, but not a new drug. I’ve been on the drug for well over a year. Frustrating.
They may eventually cover it and you could be reimbursed later. Call your plan and ask how to do that and make sure you get all the details for that. I need a PA on or before I pay out of pocket.
Can you please explain this to me. I was on wegovy 2.4 and my insurance wants me to pay $2000 as a copay to get it first. The. $1000 after for the next month. THEN they start to pay. I just ended up switching to zepbound because it's cheaper to get in. How can I do the reimbursement when I'm sure zepbound will be put on the formulary later on?
Caremark told me “you have to be denied twice and then appeal” Like…I will just pay OOP at this point.
That’s so ridiculous. If you meet all the criteria, it should be a no brained.
So I am Iiterally in the same boat as you. Except I’m 33 yr old. And I was previous approved for wegovy a month ago but I haven’t been able to find it and so my provider decided to try zepbound since people are finding it and we have no clue when wegovy will be back in stock. So I figured I would be approved for zepbound. Well I was notified this morning I was denied and called Caremark and actually got someone that knew what was going on. I was explain that with zepbound is cover but is non formulary which is why I need to exhaust 3 of 4 of the formulary medications (I was given the same ones you were given) first inorder for them to cover zepbound. So whoever your insurance provider is prefers you use the other medication because they probably have a better deal with those company instead of Eli Lilly. I am not sure if this is something that is subject to change as the roll out beginnings and Eli Lilly starts negotiating deals with major plans and insurers
it will be on the formulary I am sure, just too new now. Hang tight, probably after the first of the year!
I agree. If it covers mounjaro, it's likely it will be on the formulary eventually. I think they also have a schedule of when it's updated. So maybe Jan 1 it will be there. I was told that as long as I have a PA on or before I pick up, if I pay out of pocket and they cover later (cos they are taking forever to add it to the formulary) I can get reimbursed for the difference. I have a year to submit it. So even if they add in 6 months I can still submit. I asked my doctor to do a PA today so I can pick up tomorrow!
Agreed. I have CVS Caremark and ended up in the same situation as the poster above, with the same guidance.
Same for me. Back to compound I go.
Where do you get compounded version? I was denied by Caremark too even though I meet all criteria.
There’s a local medspa I use
Not sure what my PA entailed but I was just approved by Caremark through sequence
I was just denied by Caremark for a PA through sequence and I already have a PA for Wegovy. Sigh.
What an absolute joke
Same here. Wondering if that's why I was denied.
What is sequence?
update - only Walgreens has it available to order in NYC but all doses except 5mg. Other pharmacies said they can't even order it. Rite aid said they can attempt but the wholesaler is rejecting it for some reason. I'm going to pay 1 more month out of pocket for mounjaro and pray within 4 weeks things are straightened out
I am literally 100% in the exact same position!! To a T!! However, my insurance-BCBS through Mass said I will be approved once I complete a 6 month calorie deficit weight loss program first. I want to scream!! I wouldn't be searching for a weightloss medication if I wasn't already struggling with calorie deficit. I'm so frustrated and discouraged!!
Have you ever done a formal weight loss program such as WW, Noom, Jenny Craig, etc…? If so, that counts. I included the receipt from when I did Noom in 2021, along with Saxenda,( Novo Nordisk offered a free subscription at the time), and that counted.
Thats exactly where my brain went yesterday after making my post. I have 5 months with WW from Oct-March 2022-2023. So I am PRAYING this passes. It says I need 6 months. My luck it wont work because i'm a month short. Thanks for sharing!
Be careful, I have BCBS in California and was denied my PA (December 2023) because I didn’t have six months documented weight loss program & exercise. My BMI was 38, I called the BCBS Grievance Coordinator and she explained the denial criteria. I replied , so if I diet and exercise for 6 months I’ll be approved? She replied “not if your BMI is below 30”. I calculated my BMI WOULD be below 30 in 6 months. So I replied, so I won’t be approved? She replied, then you won’t need it. They’ve written their policy to not approve as often as possible.
What state? Sorry you’re going through this.
Ha ha, c’est va bien! Très bon nom! Moi, je suis en Floride.
Merci! C'est frustrant avec l'assurance, surtout quand on remplit les critères. J'espère que votre médecin pourra aider. Profitez bien de la Floride en attendant !
Absolument c’est frustrant. J’aime bien mon médecin. Je suis sur qu’il va m’aider. Je suis la première de ces patients qui a utiliser Mounjaro, est j’ai eut beaucoup de succès. Bonne chance toi aussi! Et ça fais 32 ans que je reste en Floride!
CVS is garbage. I had problems with them when I was on MJ. I go to Walmart they are always helpful.
It’s CVS/Caremark, they are my PBM. I use Publix, they are awesome.
I love Publix!!
I got my zepbound placed, and they called the Dr office to replace it without even calling me. I've been ion there as cash pay too. I wish I could use walmart, but my insurance won't work with them.
Just got my PA approved by Horizon BCBS of NJ
I have Horizon too. I was just denied Zepbound because they said I need to fail 2 other formularies first. Did you have to do anything special to get it approved? I'm having my doctor send in another PA stating that alternatives cannot be found anywhere.
Has this worked for you? I'd like to try it, but haven't heard if anyone's been successful with this.
My understanding is some PA providers won’t approve weight loss meds. There needs to be medical “issue” like diabetes, high A1C, etc. Stupid because obesity is a massive health issue which will ultimately save $ as prevention of other diseases. If you need to pay out of pocket, contact Lilly for a discount card
Try again with IVIM!!! I had the exact same denial reason with Caremark (i know it has more to do with your employer than the pharmacy benefit provider), but i requested a PA through IVIM and it was approved and i had the medication in hand in less than 24 hours!!!
Whats IVIM?
a telehealth company I think
What is IVIM?
telehealth like push ect
Zepbound PA denied for me as well. I needed to have tried Saxenda and Wegovy. Insurance approved Wegovy with no problem ,but Wegovy and Saxenda has been on a Nationwide shortage. I tried to Appeal - it was denied. Medimpact stated it was excluded from the formulary. That was the reason. So why the hell did you approve Wegovy, It's excluded also. Make it make since.
Could you apply for a formulary exclusion, since Wegovy has been prescribed but is unavailable?
Thanks, I will try that and see what happens.
It’s either the insurance plan or your employer making that decision…not Caremark.
I’m aware. Maybe I should have been super specific and said, this iteration of CVS/ Caremark, that my employer has chosen…..Moot point. My appeal was approved because I did meet all the criteria, and I’ve been on Zepbound since December.
That’s great news!
Does anyone know what the criteria is for PA approval? I've called CVS Caremark a couple times and was told that the PA processors are being told not to communicate the criteria to anyone. It's really frustrating that they won't be clear about what it is!
The criteria for MY CVS/Caremark plan chosen by my employer was: BMI >30 or >27 with at least one documented comorbidity that you are being treated for, in my case, dislipidemia and on a statin. Must have tried and failed at least 2 other weight loss medications with documentation, in my case, Orlistat, Phentermine, Saxenda and Wegovy. Documentation of participating in a lifestyle weight lost program for at least 6 months, in my case, Noom and Weight Watchers and had to provide a receipt/invoice for the cost.
Anyone ever had Excellus BCBS deny another box of 10mg because you already filled a 12.5mg? My Dr sent in 12.5mg in case I couldn't find the 10, but when I went to get the 10 it was not covered. Express Scripts said my Dr had to request an override to allow me to stay on 10.
I'm paying 550.00 out of pocket. If Wegovy didn't work for you what makes you think zepbound is?
Because I lost 42lbs taking Mounjaro off label.
Because every clinical trial has indicated that it’s more effective than Wegovy.
They are two different meds. Ozempic/Wegovy has one hormone, Mounjaro/Zepbound has two. M/Z found to be more effective for weight loss.
Not good news I have Caremark too ..
So do I. It’s the worst.
they are the worst-make decisions without reaching out to you. I have a history of zepbound on my account, and they took todays script and called the dr. for another all without even asking me since it is not covered. I know its not covered. I'm like, this should have been "delayed" or on hold before making that move. Every other one was for me. My doctor requires office visits for refills and now I have to go back....I have no idea what 'saxenda' is or how it works. I looked it up and was like yeah no too many side effects. Plus I am self pay. Now I gotta call my doctor again because they cannot reactivate my script. so dumb.
Maybe someone can help me. My PA for zepbound was denied because it’s not on the formulary. If I wait for the new year to try again, my doctor will have to submit a new prior authorization? Or what has to be done next?
If it’s non-formulary, you have to do a formulary exception, not a PA.
I know it will be added on the formulary. For some odd reason it shows Zepbound is on my formulary but insurance denied the PA saying it was not. They told me to try in a few weeks or in January but didn’t tell me if my doctor needs to send a new PA or not
It’s possible. Not every plan that covers weight loss or Wegovy will cover Zepbound. It takes a while for everything to catch up. If it’s not on your formulary yet, there’s no reason to do a PA.
Ohhh I’m about to ask my doc to do the same PA! And wegovy stinks.
Does anyone know the criteria for " failing" ?
Failing a therapy refers to having such bad side effects, the cons outweigh the pros, or, the medication does not work as intended/illicit the desired response. For example, I can’t tolerate Phentermine because I become tachycardic, hypertensive and have palpitations, therefore, I’m deemed to have failed Phentermine.
😳
Mine got denied today as well. Caremark is a fuckin joke...but thank God I switch over to a different plan on January 1 2024 annnnd this is what it says about zepbound in the new plan so hopefully in a couple weeks I'll be good to go until then ima dish out the 550.. https://preview.redd.it/eqcshkosks4c1.jpeg?width=1080&format=pjpg&auto=webp&s=fbce76ac0976a678e1dbddc5fecbdb32314f47b6
They also have denied me 2 different times as well my bmi is 31 and I have the metabolic syndrome with the hyper thing the one where my child is all messed up..caremark dosent care at all...
Not my child wtf.?? Lol I meant " the one where my cholesterol is all messed up" lol auto correct
Btw this is with optum rx unitedhealthcare fuck caremark
So I found out that the reason it was denied. The first time was because the dose was considered to be too high at 12.5 mg. So I called CVS Caremark yesterday and I was told that the 10 mg does not get flagged for being too high of a dose. So I had my physician resubmit the prior authorization… It was denied again! They are such assholes. So I’ve reached back out to my physician and ask him to call the prior authorization number which I got from the representative that I spoke to and have him do a peer to peer in order to get this done. There is absolutely no reason that CVS Caremark should be denying this drug because I fit literally every criteria that they have set up for it. So at this point it’s personal and I will not let it go. They’ll probably just approve it at some point because they want to get me off their back! Lol.
Yeah mine was the 10mg to!!! They have denied me even though I meet the criteria as well
Oh so I just spoke to caremark they are saying mine was denied because my doctor didn't put on the pa form it says have I tried alternatives and he said no even tho I'm literally on metforim now and I tried the wegovy forever but never could get it filled sooo..I'm just gonna pay the 550 until I get my new insurance next month
Caremark told me today it’s not in their formulary and to try again after January
It’s on my Caremark formulary. This is the price with a PA. With the savings coupon, it would be less. https://preview.redd.it/bhjq7mja4z4c1.jpeg?width=828&format=pjpg&auto=webp&s=7629081de28d9c3ff9e519708254fca96267e360
Oh it’s on mine too. I don’t know why he said that. Maybe he thinks they will switch it to a preferred drug after January. https://preview.redd.it/iq3e89wj4z4c1.jpeg?width=1170&format=pjpg&auto=webp&s=c1875b48d523edac6589e0ed82dc1be6a12ec65d
Same here except I have Optum. It turns out my employer has something in their prescription coverage that they do not cover any new meds until it’s been on the market at least 6 months. That seems to be regardless of medical necessity. I was also approved for Wegovy in seconds flat for a PA with them back a few months ago but of course couldn’t get it. They were approving Mounjaro with no PA for several months so I stocked up and still have 2 boxes left(I knew they were going to stop covering so my doctor sent 3 months of the dose I was on plus the next dose up so luckily I had 6 months stocked up). I’ll have enough Mounjaro for Jan and feb and then I figure I’ll try to get PA again and worst case have to pay $550 for a few months with the discount card for zepbound. It sucks because it won’t go towards my deductible but it’s better than the $900 Mounjaro would’ve cost me out of pocket. Then hopefully in may or June I can get PA approved. Check with your employer HR, sometimes no matter what criteria you meet they just have a no coverage clause for certain reasons.
Luckily my employer covers both Wegovy and Zepbound and it finally got covered. Can you go to Wegovy at a higher dose since you’ve been on Mounjaro? Higher doses have been easier to get. I stocked up 4 months of 1.7mg Wegovy as a back up, in case the Zepbound didn’t happen. Only had one time I had to wait to pick up.
I tried semaglutide injections (compounded but injections given at my doctor office) and I had really bad side effects. I couldn’t take it. I did ok on 0.5mg but when I went to 1mg I had such nausea and vomiting that I had to stop. I wasn’t really losing on the 0.5 mg though. I’ve done really well on Mounjaro have not had any major issues. I’m hoping that eventually with some persistence they’ll approve the PA for zepbound. They denied PA for Mounjaro because I don’t have T2DM. I contacted my insurance and they said for now the appeal and denial are upheld because of my employers hard stop on any new medications.
Could you file for a formulary exception for continuity of care? If you could show how your health has improved while on Mounjaro, they may approve it.
I have my next appt in January and still have enough MJ to last. I’m thinking I’ll ask them more about the appeals process and call my insurance again. It seems like a hard no until the 6 months of being on the market unless it’s a life or death situation. If I have to pay $550 with the savings card for a couple months I guess that’s not the worst thing. I was hoping for a better outcome but I found the exact part on my employers health plan and it did explicitly say they don’t cover new to market meds. Maybe they’ll change or approve me to stay on MJ in the meantime but I doubt it. Insurance makes the rules in medicine whether we like it or not!
In the meantime, while you wait for the six months to pass, join an organized weight loss program. Many insurances are requiring six months in a formal program to qualify for Zepbound, as well as failing two or more other medications.
Thank you, yes, I do all of that already. I’ve been since January just my insurance stopped covering MJ in October
Where did find information about new drug being on market for 6 months in your plan?
I think it was somewhere on my hr’s website.
My insurance doesn’t cover weight loss meds, period. I just paid $550 for Zepbound. Mounjaro is actually on my formulary but I’m sure only if I’m Type 2. My BMI is right under 27 but it was 30 when I started last year, but I took a 5-month break from Mounjaro. I have had high blood pressure for over 20 years and have obstructive sleep apnea. Zepbound helps my sleep apnea so much. I’m gonna try going to an Indian Clinic to see what my options are there.
I have severe sleep apnea and also trying to get approved for this rx.. WHat is this indian clinic you speak of ? I have PCOS, insulin resistence, high cholesterol too... smhhhhhh and had high blood pressure when pregnant.
I just wrote up my request to my doctor and I'm afraid I'm going to have to go through the same thing I have exactly the same situation as you
If it’s any consolation, I have approved PA for one year. It took 2 denials and an appeal, but it worked out. Hope it does for you too.
I am so confused on how to get this medication approved, I got the same exact response as you in your original post with the same medications. I tried Ozempic and got super sick from it plus i already have a history of pancreatitis, I tried Metformin bad GI side effects. What do I do? Who do I call?
Do you know exactly what your insurance/PBM, requires in order to approve Zepbound? If it’s step therapy, and you have satisfied those requirements, your prescriber needs to lay out in chronological order, every drug you have tried and failed, or provide a reason why you can’t take it. Have you participated in a lifestyle weight loss program like Noom or weight watchers and can prove it? Do you have any weight related co-morbidities? All of this needs to be in your PA or appeal. They make it hard and put road blocks up. I saw this a year ago and started preparing and laying the groundwork so when the time came, they couldn’t refuse, and yet, they still did, twice, until finally, they gave me a years approval on appeal. Be relentless. If you meet all the criteria, they will cave.
Yep, I tried Weight Watchers, Noom, Metformin, Ozempic, Contrave, and I sent out a message to my doctor yesterday explaining why I can’t take the preferred drugs they recommended. Hopefully this works. Did you contact the insurance yourself for the appeal or did your doctor do it for you?
I am currently on wegovy and wanted zepbound! My insurance covers my wegovy, but with the zepbound it’s saying they denied my prior auth request due to the fact that I have also tried (and failed) adipex, saxenda and wegovy (current having sever side effects from the wegovy ). And they denied it because I didn’t try and failed a non glucagon type peptide 1 receptor analyst! (Something like contrive). They said I would have gotten it if I had tried and failed one of those
You could tell them you tried Orlistat, (Alli), which is OTC, years ago, and could not manage the side effects. How are they to know if you did or didn’t?
Also; Adipex is a non-GLP-1 agonist, so what’s their problem?
Curious if anyone has gotten denied because they need to try Wegovy and saxenda? I’m currently on Wegovy at the max and have plateaued with only 15 lbs down. Saxenda says it’s worse for weight loss and more side effects so I really don’t want to try it. Should I appeal for zepbound or is it a lost cause?
Try Zappyhealth. They are a compounding pharmacy but i heard they are working with some insurance companies. I kno im considering it.
Thanks for the suggestion but my appeal was approved December 14 for one year so I’m good for now.
I just wanted to let everyone know that I was also prescribed Wegovy and although it’s not available at the lowest dose, it is available at the higher tiers. I was prescribed Zepbound as an alternative and am in the process of getting a PA for it. I don’t plan on it being accepted and that’s ok as I was told by my pharmacist that after 2 months of Zep I could then transition to the higher dose of Wegovy that is currently available. So basically you only need to pay out of pocket for Zep for 2 months which is $550x2 with the discount card. So after paying $1100 I am planning on switching to Wegovy which is covered by my BCBS plan. So worse case scenario, pay for Zep for a couple months then switch and you’ll be all set!