As the title states I was recently prescribed zepbound by my primary car physician for weight loss due to weight gain from a medication I take, paired with a sedentary life style due to a career change. Im currently weighing in at 275lbs at 26 y/o, 125lbs heavier than I was 3 years ago. I just now came across this sub while looking through my options. I didnt get a reason for the denial, the pharmacy just called and said that insurance wouldn’t cover the medication and I didnt think to ask further because I didnt think there was anything more to do.
My insurance is Blue Cross Blue Shield that I have through that I have due to my employment at the Post Office. Im also an apprentice with the Operating Engineers union, and have insurance through them but I keep the PO ins as my main because its more stable.
I have found a slight workaround through Henry Meds where Im getting compounded tirzepatide injections, but its still $450 a month, and while I can afford it, its still a significant drain on my finances.
My question is, is there any way to negotiate with a health insurance agency, especially one as big as BCBS? Could my doctor “fudge the numbers” in such a way to make it seem more preventative? Any advice would be extremely welcome. Im brand new to dealing with my own health insurance as I just came off my parents a year ago and have never had any issues until this came up.
Some more context. If it would help my case, I was always a big kid but when I was 18 I weighed 250, but I cut my calories down to 1000 or less a day, and within a year I had lost 80 lbs, and manged to keep it off until I was 23 and started this new medication. Ive reverted to the 1000ish calorie a day & intermittent fasting diet with the help of a dietitian with almost no loss in weight. Dont know if any of this paragraph is relevant but just in case it is its here. Thanks in advance for the insight.
It depends. Does your insurance cover weight loss? Many plans treat weight loss like cosmetic procedures (like Botox or liposuction), meaning it’s often self-pay. They might cover doctor visits or related fees, though.
It doesn’t matter if your doctor tries to “fudge” anything—weight loss isn’t considered preventive since you already have the weight. Plus, asking your doctor to commit fraud isn’t a good idea.
You should contact your insurance or HR to find out if weight loss is a covered benefit. If it is, ask what steps you need to take. Sometimes coverage requires working with a nutritionist, counseling, or proof that you’re following a plan.
What does your formulary say? Your plan is likely an FEP plan. If a drug is excluded in the formulary or plan, it’s hard to win an appeal since it’s a contract exclusion. However, if a drug or service just needs prior authorization and gets denied, you can appeal based on medical reasons.
There are also many BCBS companies. Plans for government employees are part of the “Federal Employee Program,” which your local BCBS company manages. Starting next year, the Post Office will have its own plan.
First, don’t ask your PCP to “fudge numbers” because that’s insurance fraud.
Instead, ask your PCP about other types of GLP-1 medications. Then, contact BCBS and request the coverage policies for those medications to check if prior authorization is needed. The coverage policy will explain all the reasons the medication is covered and considered medically necessary. It’s hard to bypass these policies.
You’ll need to dig into the denial reason. Unsure if it’s a plan exclusion or if there is step therapy that hasn’t been completed. You’ll want to check for any correspondence or notices within your online portal.
If you share the exact name of the federal employee health plan you’re on, we can dig in a bit further and help locate medical policies and / or plan exclusions.
No. They either cover it or they don’t. Before you were prescribed the meds, you could have determined that they don’t cover it. They may in the future, but they don’t at this time.
Are you diabetic? Mounjaro is the same medication but prescribed for diabetes. If your insurance is self-funded, you can ask your employer for assistance. My company’s self-funded insurance covers all the weight loss medications, but I know I’m lucky. Many other insurances, especially those from the exchange, don’t cover it.