Why won’t insurance cover ozempic for pre-diabetics?
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Anonymous
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We pay roughly $900/month for our employer sponsored CareFirst plan. I am pre-diabetic and the plan won’t cover Wegovy or any of the others for me. It’s much too expensive for us to afford out of pocket.
Irony- my spouse is a health care provider and this is the insurance that is offered to employees. It’s terrible. Our out of network deductible is 20k! |
Anonymous
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FEHB requires Tx of obesity. That varies between plansFEHB is push them to be covered like any medication for chronic conditions. For BMI 25-30 plus one weight related illness (hypertension, high cholesterol, pre diabetes) or BMI 30+ with no co-morbid condition, Wegovy is covered. On the standard plan, it’s about $360 a month, but there is a one year, $250 per month coupon. So, $110. Once I’m on a stable dosage, o AP an mail order for a $90 co-pay (I can’t tell if that’s 28 or 84 day supply).
Pre-authorization took less than 2 days. |
Anonymous
You are taking Wegovy. |
Anonymous
It's not the insurance plan, it's the plan your employer negotiated with the insurance company. I had a Cigna PPO under my previous employer and they covered wegovy. I have a Cigna PPO under my new employer and they do not cover Wegovy. |
Anonymous
OMG. You guys are such idiots. You need to talk to your HR. They negotiate coverages with insurance companies. If your insurance plan doesn't cover it, it's because your employer said no. |
Anonymous
| Supposedly the federal plans cover it for pre diabetics. My Carefirst plan does not. |
Anonymous
You are the idiot. Some of us are self-employed and must buy health insurance through the exchange. |
Anonymous
And we're all idiots to enrich health insurance executives rather than having nationalized health plans. |
Anonymous
Which would also be an enormous incentive to do more preventive care like weight loss medication. |
Anonymous
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I’m also on Carefirst and I was able to get covered for Ozempic.
The caveat is that I had to have completed step therapy by using metformin first. I had labs and have no kidney issues so Dr was good with prescribing metformin. Once I filled the metformin I had no additional requirements for Ozempic. I chose to instead use Mounjaro to treat my obesity and metabolic syndrome. It took several attempts to get it approved and insurance wanted me on Ozempic instead. Please check your policy and ask your insurance for a copy of your prescription formulary or look it up on the portal. My formulary clearly stated that for Ozempic, a prior authorization (PA) was required if step therapy was not done. New policies are coming out though regarding Ozempic and similar medicines where access will be restricted to type 2 diabetics primarily. You can still file a request for a PA but it will be harder to get approved |
Anonymous
No, PP is likely taking Ozempic. I also am taking Ozempic purely for weight loss and insurance covers it. |
Anonymous
And some of us have small group plans. Those employers can't negotiate from what I understand. |
Anonymous
| My doctor doesn’t medicate for pre-diabetes. Maybe it’s not considered necessary? Or maybe they only cover metaforfin? It’s cheaper. |
Anonymous
Yes, they are the same drug. My prescription is for Ozempic and I use Ozempic, not Wegovy. |
Anonymous
Lol at calling weight loss medication preventive care. Preventive care would be to not get to a place of needing this medication in the first place. |