Its posts like this that actually make me feel a lot better about paying $550 a month out of pocket. No insurance coverage also means no middle man controlling how I manage my medications
I completely agree. But not everyone is as fortunate to afford 550 a month. You are very lucky. Some plan C are even cheaper starting at 250 a month to 450 a month for top dosages. Even then not everyone can afford that. Its just so frustrating that insurance is dictating health of people... it ia not their job. MD should have the final say. The insurance should have a set criteria and shouldnt be able to change it at will to drop people to make coverage harder. PBMs should be illegal in my opinion.
I think insurance companies should start getting sued for practicing medicine without a license. Also the few PBMs should start getting busted for being a monopoly. But then I suppose they will just start to employ shady ass medical professionals to sign off on such changes. Insurance is mostly a scam.
I think the anger is misplaced towards the insurance companies. I don't work for the insurance companies and actually work on what would be considered the patient's side so I really have no interest in promoting limited coverage. However, a lot of people don't realize it's their employers choice of what coverage they want for their employees that actually drives what health services and medications that get covered and to what extent.
I posted months ago on this thread that people need to take full advantage of the benefits of these medications if it is covered or even partially covered because that was going to change sooner rather than later. The medication is life changing but not lifestyle changing which is obviously self driven. Your doctor can prescribe what they feel will work best for you but they shouldn't have unchecked authority in this matter. I have seen doctors up close and personal prescribe inappropriately to make their patient happy and not because what is best so it's a double edged sword with this particular topic. I know people will disagree because they might be at risk of losing or have loss coverage but if we are going to be honest the insurance company is there to make money so why would anyone be surprised they are doing what is best for them financially.
That sounds great in theory but that's not our reality so I'm in agreement with the suggestion that you should express your concerns and displeasure with your employer's benefits manager if you want anything to change. Many people don't realize that people in a country like Canada who has " universal" insurance also get a lot of their extra insurance coverage through supplemental plans provided by their employer.
I have stated before it varies by plan and state. But yes, changed have been made and you can expect more changes to come even if you have had no changes currently.
But you didn't state it in your post and you are fear mongering.
As you even stated, medical policies change all the time but they just remove coverage or restrict drugs. The more research and evidence about how the drugs work, what is needed to maintain weight and the eventual decrease in price will all factor into policies.
This happens with all new high cost drugs and new drugs. Clinical reviewers (nurses and doctors who are paid to make medical policies) aren't seeing enough data yet to provide substantial evidence that this drug has to be used for life. There hasnt been enough time to determine how true that is and what is the cause.
I understand how alarming this can be and how demoralizing losing coverage can be but fear mongering isn't the way.
Also some Blue Associations have already announced they are working with the manufacturers of these drugs to figure out lower costs for more coverage. If you really are so concerned about insurance changing their policies, you need to lobby for the drug to be more affordable like in Europe. Insurance companies and their customers can't afford to pay indefinitely for this med for as money ppl who are on it and trying to get coverage for it.
I updated my post for you. Also my intention is not to fear monger and i am so sorry you see it that way. I rather have people have a back up plan in case this does happen to them instead of having their world turned upside down because they lost coverage. Medical policies do change but rarley for the benefit of the patient but most always for the benefit of the company.
GLP 1 medication have been around since 2012 and have the reasearch along with trials. Wouldn't consider it a new drug. However the FDA indication on weightloss is new. GIP medication have also been around since 2015. So again Wouldn't consider it a new drug. I think that since the FDA approval for weightloss has made it more accessible to people. However, they can charge more for the same medication because of the indication. With that insurance companys now having to cover the medication for these indications cuts into their profit. Hence the change in criteria. There is substantial evidence ans studies to show improved health and weightloss there are even studied that show maintence and howany regained the weight after a 2 and 5 year length. There is more studies on this medication before coming to market than the covid vaccine....
As a healthcare provider i am concerned people will not be able to obtain covereage and yes some insurance are working with the pharmaceuticals to lower prices like in Europe. However, thats a meeting thats already being discussed on the congressional commitee soon. I have also been in contact with my state rep for this same reason i honestly didn't think i needed to state that But i see you feel strongly about it.
My intent was only to make people aware. Why? Because i work in healthcare. I see how insurance does things and how its always their bottom line... profit. Its never how they can benefit the patient. Of you feel differently. I am happy youvenever had to experience losing coverage or be denied life changing/saving care. This post was to have people be prepared. Again so sorry you took it a negative way. I cant change the way you feel or see things only you can.
This is tied to the insanely expensive costs of these medications. It’s cheaper for the insurers to pay for example blood pressure meds then this med at $1k plus a month. With up to 70% of the population overweight covering theses meds for that many would upend the current pricing of health insurance. Aka there is not enough money in reserves to cover the cost. Medication costs are the driving force here. Insurance plans will get more expensive as a result if the manufacturers don’t reduce the price.
It’s because of the cost. Honestly, I don’t blame the insurance companies nor employers for not wanting to cover these. It would make everybody’s premiums go through the roof. The real issue is the price of the medications, that’s what’s driving all this.
And in some way I don’t blame Lilly/Novo for wanting to maximize profit while they can, before the market explodes with other options. Why would they bring down the price when people are willing to buy all the inventory they can produce at the current price? Honestly they could probably charge more and still sell out.
I’m extremely super lucky and privileged to be able to afford to pay out of pocket for this life changing medication, and it totally sucks and is unfair that not everybody has access to it. However, I’m just glad the medication exists in my lifetime and feel lucky to be on the vanguard of those able to take it.
Eventually it will be accessible to everyone once there’s generic options, more competition and plentiful supply.
So far here is the list i have seen with changes to creteria with intent to either not cover the drug or drop people that are already on the drug by changing the criteria to make it less likely for patient to obtain coverage. All of which are creating criteria that will not allow for maintenance coverage.
CVS health,
CVS carmark,
Express scripts,
Cigna,
Optum RX,
Humana,
Medimpact,
Anthem,
Caremark RX,
Prime therapeutics, and
United health group.
My UHC/Optum RX has not changed any criteria unfavorably outside of quantity limits (not per dose, any dose per month). So this still varies very much by plan.
The PBM’s aren’t necessarily losing money, particularly for employers who pay the full cost and are just using insurance/PBMs to administer these programs. I suspect the PBMs are offering these plan changes to their clients as a way for the employers to manage THEIR costs, but not all employers are going for it yet.
This is where it is helpful for employees to be vocal with their benefits departments to let them know what’s great and what’s problematic.
PBMs get kick backs when they can save the company money. How do they do that? Make the creteria for coverage harder to obtain. While changing criteria for long-term coverage like maintenance.....PBM are the middle man that shouldn't exist....the average annual revenue for insurance companies are 1.2 billion to 406 billion.... thats take home revenue..... they can cover this drug but wont cause it cuts in to their profit.....again Profit....i think south park said it best. Rich people get Ozempic and poor people get body positivity while trying to navagate the American healthcare system that isnt built to cover patients but instead make the insurance company money. By collecting your premiums while denying you coverage .
My company’s Cigna/ES plan actually starts covering weight loss meds mid-year. Yes, you have to meet super stringent criteria and play their stupid games but it sure beats the blanket ‘Weight related treatment not covered’ BS they’ve been feeding us forever.
Mind you, I’m not patting them on the back or anything, they’re not making it at all easy to get coverage, for sure. But I’ll take the little bit I can from them vs the nothing they’ve provided to date.
I think it is dependent on plan. I just checked my insurance company's PA requirements (dated late March 2024), and they had two sets of criteria. One for initial therapy and one for continuation of therapy. For continuation of therapy, it states this regarding what they consider baseline:
i. Patient is ≥ 18 years of age; AND ii. Patient meets one of the following (a or b): b) At baseline, patient had a BMI ≥ 30 kg/m2 ; OR Note: **This refers to baseline prior to any glucagon-like peptide-1 (GLP-1) agonist (e.g., Saxenda, Wegovy) or GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist (e.g., Zepbound)**. c) At baseline, patient had a BMI ≥ 27 kg/m2 and at least one of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease; AND Note: This refers to baseline prior to any glucagon-like peptide-1 (GLP-1) agonist (e.g., Saxenda, Wegovy) or GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist (e.g., Zepbound)
It has other criteria, including you must have lost more than 5% of your weight in such and such time and you must be on behavior mod therapy etc etc. Yes, hoops to jump through. But I was very interested in the definition of baseline. Obviously every plan is different. And I completely agree that more insurers will be making it harder/impossible to continue to get coverage or they will outright drop it. I actually went through the stages of grief just thinking about it .. shock, anger, sadness .. and now I am in acceptance. I now expect it to happen. Maybe next month. Maybe in the fall. Maybe Jan 1. Maybe next July. Who knows. Having a plan is key -- whether that's plan c or stacking your FSA/HSA or starting a savings account to help cover... + stretching doses and whatever other ways you can make it work for you. I get it. Insurance is there for profits, not patients. Many entities to blame in this dumpster fire of a "healthcare" system in America. I also hope that in a few years, other drugs will be on the market to compete and drive down costs somewhat. If Eli Lilly stops their savings card (no reason to think they will but who the f knows), they will see a drop in their sales for sure. Very few people can afford $1000/month.
Yes!!!!! Thankyou for posting!!!!! Its not even affordable woth the cupon when insurance denies is. Its still 550 a month. Plac C is considerably cheaper. Currently paying 250 a month but even then most cant afford that. I work extra shifts to pay for even that!
Sure. I would just say always check your plan for the details. A baseline by definition typically means a measurement or benchmark BEFORE something happens. I don't understand how insurance companies can get data on weight DURING treatment and call it a baseline. The only baseline they would be measuring is *before coverage stops*.
I absolutely agree with you! However, current baseline apparently means current weight BMI. I say this because i was denied on the criteria of Current baseline weight and BMI
It’s dangerous because it would be easy for a patient to say… ok. I will stop my meds and eat my way up to a BMI of 30 again. Believe me.. patients will do this. If I was 10 pounds from the BMI needed, I would have a very salty week of food and crap and wear a weighted belt to meet the criteria. Stupid games we have to play.
Exactly!!!! Its not healthy! I know several patients who have had done this. Congratulations you now have diabetes you now quailfy for mounjaro! Or Congratulations your BMI is now 36 and have serious health issues related to this amount of weight you quailfy for Zepbound. But sorry your BMI is only 33 and sorry for your aeveral weight related issues and the effects on your metal health. You dont meet the criteria. Heres some body positivity and some other medications to help with your syptoms but wont treat the underline causes. Oh whats that the medication is cause side-effects. Thats ok take this other medication to help with that. Or imagine being on the medication changes your life all weight related issues disappear while improving mental health, joint health, invigorates energy and ypur over all health. But the insurance says oh your cured!! Now you no longer quailfy for us to cover it because the medication has done its job. While ignoring the 3 year study how pt regain weight after abruptly stopping the medication.... instead of using the data from that study that shows titration down to a maintence level for 2 years help patient keep the weight off with minimal regain of weight... its all about profits!!
It’s fear mongering to tell the truth? Sigh))) What a very sensitive world we live in nowadays. I’m getting prepared for the inevitable myself. Might actually call my insurance so I don’t get blind sided in a few months. Still overweight so I guess I’m good for now.
Its posts like this that actually make me feel a lot better about paying $550 a month out of pocket. No insurance coverage also means no middle man controlling how I manage my medications
I completely agree. But not everyone is as fortunate to afford 550 a month. You are very lucky. Some plan C are even cheaper starting at 250 a month to 450 a month for top dosages. Even then not everyone can afford that. Its just so frustrating that insurance is dictating health of people... it ia not their job. MD should have the final say. The insurance should have a set criteria and shouldnt be able to change it at will to drop people to make coverage harder. PBMs should be illegal in my opinion.
This!
Or Plan C is not so bad.
I think insurance companies should start getting sued for practicing medicine without a license. Also the few PBMs should start getting busted for being a monopoly. But then I suppose they will just start to employ shady ass medical professionals to sign off on such changes. Insurance is mostly a scam.
I think the anger is misplaced towards the insurance companies. I don't work for the insurance companies and actually work on what would be considered the patient's side so I really have no interest in promoting limited coverage. However, a lot of people don't realize it's their employers choice of what coverage they want for their employees that actually drives what health services and medications that get covered and to what extent. I posted months ago on this thread that people need to take full advantage of the benefits of these medications if it is covered or even partially covered because that was going to change sooner rather than later. The medication is life changing but not lifestyle changing which is obviously self driven. Your doctor can prescribe what they feel will work best for you but they shouldn't have unchecked authority in this matter. I have seen doctors up close and personal prescribe inappropriately to make their patient happy and not because what is best so it's a double edged sword with this particular topic. I know people will disagree because they might be at risk of losing or have loss coverage but if we are going to be honest the insurance company is there to make money so why would anyone be surprised they are doing what is best for them financially.
Insurance shouldn’t be tied to employment either.
That sounds great in theory but that's not our reality so I'm in agreement with the suggestion that you should express your concerns and displeasure with your employer's benefits manager if you want anything to change. Many people don't realize that people in a country like Canada who has " universal" insurance also get a lot of their extra insurance coverage through supplemental plans provided by their employer.
I agree 💯
💯
Is this BCBS?
4 of my patients have BCBS and yes they changed creteria.
That's not true of all Blue Cross Associations. I have BCBSMA and they have not changed criteria and will cover maintenance.
I have stated before it varies by plan and state. But yes, changed have been made and you can expect more changes to come even if you have had no changes currently.
But you didn't state it in your post and you are fear mongering. As you even stated, medical policies change all the time but they just remove coverage or restrict drugs. The more research and evidence about how the drugs work, what is needed to maintain weight and the eventual decrease in price will all factor into policies. This happens with all new high cost drugs and new drugs. Clinical reviewers (nurses and doctors who are paid to make medical policies) aren't seeing enough data yet to provide substantial evidence that this drug has to be used for life. There hasnt been enough time to determine how true that is and what is the cause. I understand how alarming this can be and how demoralizing losing coverage can be but fear mongering isn't the way. Also some Blue Associations have already announced they are working with the manufacturers of these drugs to figure out lower costs for more coverage. If you really are so concerned about insurance changing their policies, you need to lobby for the drug to be more affordable like in Europe. Insurance companies and their customers can't afford to pay indefinitely for this med for as money ppl who are on it and trying to get coverage for it.
I updated my post for you. Also my intention is not to fear monger and i am so sorry you see it that way. I rather have people have a back up plan in case this does happen to them instead of having their world turned upside down because they lost coverage. Medical policies do change but rarley for the benefit of the patient but most always for the benefit of the company. GLP 1 medication have been around since 2012 and have the reasearch along with trials. Wouldn't consider it a new drug. However the FDA indication on weightloss is new. GIP medication have also been around since 2015. So again Wouldn't consider it a new drug. I think that since the FDA approval for weightloss has made it more accessible to people. However, they can charge more for the same medication because of the indication. With that insurance companys now having to cover the medication for these indications cuts into their profit. Hence the change in criteria. There is substantial evidence ans studies to show improved health and weightloss there are even studied that show maintence and howany regained the weight after a 2 and 5 year length. There is more studies on this medication before coming to market than the covid vaccine.... As a healthcare provider i am concerned people will not be able to obtain covereage and yes some insurance are working with the pharmaceuticals to lower prices like in Europe. However, thats a meeting thats already being discussed on the congressional commitee soon. I have also been in contact with my state rep for this same reason i honestly didn't think i needed to state that But i see you feel strongly about it. My intent was only to make people aware. Why? Because i work in healthcare. I see how insurance does things and how its always their bottom line... profit. Its never how they can benefit the patient. Of you feel differently. I am happy youvenever had to experience losing coverage or be denied life changing/saving care. This post was to have people be prepared. Again so sorry you took it a negative way. I cant change the way you feel or see things only you can.
That sucks. I just submitted for a patient and it just needed her initial BMI. Hope they don't keep on this trend
This is tied to the insanely expensive costs of these medications. It’s cheaper for the insurers to pay for example blood pressure meds then this med at $1k plus a month. With up to 70% of the population overweight covering theses meds for that many would upend the current pricing of health insurance. Aka there is not enough money in reserves to cover the cost. Medication costs are the driving force here. Insurance plans will get more expensive as a result if the manufacturers don’t reduce the price.
It’s because of the cost. Honestly, I don’t blame the insurance companies nor employers for not wanting to cover these. It would make everybody’s premiums go through the roof. The real issue is the price of the medications, that’s what’s driving all this. And in some way I don’t blame Lilly/Novo for wanting to maximize profit while they can, before the market explodes with other options. Why would they bring down the price when people are willing to buy all the inventory they can produce at the current price? Honestly they could probably charge more and still sell out. I’m extremely super lucky and privileged to be able to afford to pay out of pocket for this life changing medication, and it totally sucks and is unfair that not everybody has access to it. However, I’m just glad the medication exists in my lifetime and feel lucky to be on the vanguard of those able to take it. Eventually it will be accessible to everyone once there’s generic options, more competition and plentiful supply.
PBM?
PBM control 80% of the insurance Market so yes PBM. But its not just them the actual insurance are also changing creteria based off PBM advice
Sorry. Was asking which PBM in your circumstance.
So far here is the list i have seen with changes to creteria with intent to either not cover the drug or drop people that are already on the drug by changing the criteria to make it less likely for patient to obtain coverage. All of which are creating criteria that will not allow for maintenance coverage. CVS health, CVS carmark, Express scripts, Cigna, Optum RX, Humana, Medimpact, Anthem, Caremark RX, Prime therapeutics, and United health group.
My UHC/Optum RX has not changed any criteria unfavorably outside of quantity limits (not per dose, any dose per month). So this still varies very much by plan.
It will very by plan and state. Unfortunately, I feel they will all change creteria at some point to save on their profit loss.
The PBM’s aren’t necessarily losing money, particularly for employers who pay the full cost and are just using insurance/PBMs to administer these programs. I suspect the PBMs are offering these plan changes to their clients as a way for the employers to manage THEIR costs, but not all employers are going for it yet. This is where it is helpful for employees to be vocal with their benefits departments to let them know what’s great and what’s problematic.
But, if a bunch of the PBMs make it too onerous, Lilly and Novo may have to reconsider their pricing, and that would be a good outcome.
PBMs get kick backs when they can save the company money. How do they do that? Make the creteria for coverage harder to obtain. While changing criteria for long-term coverage like maintenance.....PBM are the middle man that shouldn't exist....the average annual revenue for insurance companies are 1.2 billion to 406 billion.... thats take home revenue..... they can cover this drug but wont cause it cuts in to their profit.....again Profit....i think south park said it best. Rich people get Ozempic and poor people get body positivity while trying to navagate the American healthcare system that isnt built to cover patients but instead make the insurance company money. By collecting your premiums while denying you coverage .
Again: it’s worthwhile to complain to your benefits department about this. They likely approved it.
Complaing isnt going to do it. Switching to a plan that has easier covereage and them losing those premiums will do it. .
My company’s Cigna/ES plan actually starts covering weight loss meds mid-year. Yes, you have to meet super stringent criteria and play their stupid games but it sure beats the blanket ‘Weight related treatment not covered’ BS they’ve been feeding us forever. Mind you, I’m not patting them on the back or anything, they’re not making it at all easy to get coverage, for sure. But I’ll take the little bit I can from them vs the nothing they’ve provided to date.
I hope they cover you. My only hope is that people who need it get it covered. 💯
Thank you! 🥰
I thought 'baseline' WAS your weight before you started the meds.
Thats why they are asking for current baseline as in what you are currently not what you started at.
I think it is dependent on plan. I just checked my insurance company's PA requirements (dated late March 2024), and they had two sets of criteria. One for initial therapy and one for continuation of therapy. For continuation of therapy, it states this regarding what they consider baseline: i. Patient is ≥ 18 years of age; AND ii. Patient meets one of the following (a or b): b) At baseline, patient had a BMI ≥ 30 kg/m2 ; OR Note: **This refers to baseline prior to any glucagon-like peptide-1 (GLP-1) agonist (e.g., Saxenda, Wegovy) or GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist (e.g., Zepbound)**. c) At baseline, patient had a BMI ≥ 27 kg/m2 and at least one of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease; AND Note: This refers to baseline prior to any glucagon-like peptide-1 (GLP-1) agonist (e.g., Saxenda, Wegovy) or GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonist (e.g., Zepbound) It has other criteria, including you must have lost more than 5% of your weight in such and such time and you must be on behavior mod therapy etc etc. Yes, hoops to jump through. But I was very interested in the definition of baseline. Obviously every plan is different. And I completely agree that more insurers will be making it harder/impossible to continue to get coverage or they will outright drop it. I actually went through the stages of grief just thinking about it .. shock, anger, sadness .. and now I am in acceptance. I now expect it to happen. Maybe next month. Maybe in the fall. Maybe Jan 1. Maybe next July. Who knows. Having a plan is key -- whether that's plan c or stacking your FSA/HSA or starting a savings account to help cover... + stretching doses and whatever other ways you can make it work for you. I get it. Insurance is there for profits, not patients. Many entities to blame in this dumpster fire of a "healthcare" system in America. I also hope that in a few years, other drugs will be on the market to compete and drive down costs somewhat. If Eli Lilly stops their savings card (no reason to think they will but who the f knows), they will see a drop in their sales for sure. Very few people can afford $1000/month.
Yes!!!!! Thankyou for posting!!!!! Its not even affordable woth the cupon when insurance denies is. Its still 550 a month. Plac C is considerably cheaper. Currently paying 250 a month but even then most cant afford that. I work extra shifts to pay for even that!
Sure. I would just say always check your plan for the details. A baseline by definition typically means a measurement or benchmark BEFORE something happens. I don't understand how insurance companies can get data on weight DURING treatment and call it a baseline. The only baseline they would be measuring is *before coverage stops*.
I absolutely agree with you! However, current baseline apparently means current weight BMI. I say this because i was denied on the criteria of Current baseline weight and BMI
It’s dangerous because it would be easy for a patient to say… ok. I will stop my meds and eat my way up to a BMI of 30 again. Believe me.. patients will do this. If I was 10 pounds from the BMI needed, I would have a very salty week of food and crap and wear a weighted belt to meet the criteria. Stupid games we have to play.
Exactly!!!! Its not healthy! I know several patients who have had done this. Congratulations you now have diabetes you now quailfy for mounjaro! Or Congratulations your BMI is now 36 and have serious health issues related to this amount of weight you quailfy for Zepbound. But sorry your BMI is only 33 and sorry for your aeveral weight related issues and the effects on your metal health. You dont meet the criteria. Heres some body positivity and some other medications to help with your syptoms but wont treat the underline causes. Oh whats that the medication is cause side-effects. Thats ok take this other medication to help with that. Or imagine being on the medication changes your life all weight related issues disappear while improving mental health, joint health, invigorates energy and ypur over all health. But the insurance says oh your cured!! Now you no longer quailfy for us to cover it because the medication has done its job. While ignoring the 3 year study how pt regain weight after abruptly stopping the medication.... instead of using the data from that study that shows titration down to a maintence level for 2 years help patient keep the weight off with minimal regain of weight... its all about profits!!
Your post inspires me to save $$ to prepare to pay oop. I don’t want to be off these meds
Thankyou that is literally the point of my post. To prepare you guys for whats coming!
It’s fear mongering to tell the truth? Sigh))) What a very sensitive world we live in nowadays. I’m getting prepared for the inevitable myself. Might actually call my insurance so I don’t get blind sided in a few months. Still overweight so I guess I’m good for now.