Express Scripts denied pre-authorization for Ozempic. What to do now?

[Anonymous]

Anonymous wrote:

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Anonymous wrote:What, pray tell, is “marginally pre-diabetic?”

If you want to lose 50, eat less and move more and cut down on carbs. That will do a lot to help your glucose too. You don’t need Ozempic.

my A1c is outside the normal range, but only a little.

yes, I do need Ozempic. I have been on a diet for the past 40 years.

See an endocrinologist. Expect to spend six months on Metformin first and be told to lose 20 before they will consider putting you on a medication that costs thousands

Go eat rocks. I’m not the PP but you are seriously not well.

NP: I don't understand your angry reaction to PP's comment. I didn't read any snark in their comment, and they're likely not wrong with their advice! Metformin is often the first step. There is a max amount of weight usually experienced with Metformin, and then you're moved to another medication. And yes and Endocrinologist is appropriate doctor for this.

Because she’s Veruca Salt as are most of the semaglutiders here. They need a quick revenge on all of the men they presume rejected them due to weight, but especially need to vanquish the thinner women they’ve been in one-way battle with over life. What are you even trying to say, go to an endo IRL and manage your health responsibly, who wants to do that?

If it weren’t true, you wouldn’t react. Most of the posts on these threads are stuffed with ladies who dream of cusp sizes and brag about how other women will “lose their advantage” once they’re on the drug, all while not being able to eat fewer calories than The Rock.

[Anonymous]

Anonymous wrote:I’m type 1.5 (LADA) which is adult onset type 1 diabetes. I’m taking ozempic until my pancreas stops working in 5-6 years and I need insulin. This isn’t a lifestyle choice, I’m not fat, and it’s genetic. But I guess op is fine with people like me struggling to get my medication because despite just people want to say, there is a shortage of the 2mg dose. It’s had to find because people are getting that dose, so they can save money paying out of pocket, when they’re prescribed a lower dose.

You kind of suck op. I don’t really have an issue with people wanting ozempic to lose weight, but op is so entitled, I hope she has to pay full price.

Also, good luck getting a pharmacist to fill your prescription, so try to get it online. Pharmacists are gate keeping this medication. More than one person at Walgreens and CVS have told me they are making sure the people who actually need this medication are getting it.

This is BS and I doubt it’s true. I’m temporarily taking Ozempic because Wegovy is out of stock. The pharmacist doesn’t know anything about my health history. It’s not their decision to make. They do not get to assume I’m trying to lose vanity pounds and therefore less deserving. Contrary to many posters’ opinions here, there ARE certain people for whom these drugs are protective beyond weight loss.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I’m type 1.5 (LADA) which is adult onset type 1 diabetes. I’m taking ozempic until my pancreas stops working in 5-6 years and I need insulin. This isn’t a lifestyle choice, I’m not fat, and it’s genetic. But I guess op is fine with people like me struggling to get my medication because despite just people want to say, there is a shortage of the 2mg dose. It’s had to find because people are getting that dose, so they can save money paying out of pocket, when they’re prescribed a lower dose.

You kind of suck op. I don’t really have an issue with people wanting ozempic to lose weight, but op is so entitled, I hope she has to pay full price.

Also, good luck getting a pharmacist to fill your prescription, so try to get it online. Pharmacists are gate keeping this medication. More than one person at Walgreens and CVS have told me they are making sure the people who actually need this medication are getting it.

This is BS and I doubt it’s true. I’m temporarily taking Ozempic because Wegovy is out of stock. The pharmacist doesn’t know anything about my health history. It’s not their decision to make. They do not get to assume I’m trying to lose vanity pounds and therefore less deserving. Contrary to many posters’ opinions here, there ARE certain people for whom these drugs are protective beyond weight loss.

This is not BS at all. When your doctor prescribes ozempic, they put in a diagnostic code and the pharmacy can see that plus your past history to see that you do in fact have diabetes. Go on r*dot and look on the pharmacists threads, they openly talk about doing this to people who don’t have diabetes.

[Anonymous]

You should ask Express Scripts to send you the prior authorization form. It’s usually about 8 to 10 questions. This way you and your doctor can figure out whether there’s a way to have it covered. It may help you and it’s worth the extra hassle.

[Anonymous]

Anonymous wrote:Op no one cares if you get Wegovy, people are reacting to you wanting ozempic and for insurance to pay for it, because as you said previously, you’ve paid a lot to insurance over the years and want something back. THAT is what people are reacting to, because you don’t qualify for ozempic and you are trying to take diabetes medication away from diabetics, by contributing to the shortages. Get Wegovy and call it a day.

Bullshit and speak for yourself. There are absolutely people who care if OP gets Wegovy and whether she gets medication at all, regardless of who pays. The people talking about "short cuts" and "doing the work" are, at best, using compliance with bureaucratic niceties as a pretext. There are people who are very irritated at the idea of other people using technology to maintain their weight.

[Anonymous]

Anonymous wrote:

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Anonymous wrote:Insurance companies decide what is covered. Not your doctor, OP. You can get a prescription, no one is stopping you. But you won’t have it covered so stop complaining, or else eat more bad food so you get full blown diabetes and then it will be covered.

insurance company does cover both ozempic and wegovy. so they already decided they would do it.

and my doctors think i need them. it's weird to me that there the company needs to make additional approval to cover the medicine they already decided to cover. if they don't want to cover wegovy, fine. but why second guess my doctor? why would they know better what i need?

My doctor prescribed me Ozempic, but my insurance company is very clear they only cover it for full diabetes, not pre diabetes. It may be a dumb policy but it is clearly the policy. I pay out of pocket. Your insurance company isn't saying you can't use Ozempic, they are just saying that they aren't covering it for you being overweight.

Part of this is because "pre-diabetes" is something of a public health scare tactic to get people to change their diet and exercise more. The diagnosis criteria are a little bit arbitrary.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Insurance companies decide what is covered. Not your doctor, OP. You can get a prescription, no one is stopping you. But you won’t have it covered so stop complaining, or else eat more bad food so you get full blown diabetes and then it will be covered.

insurance company does cover both ozempic and wegovy. so they already decided they would do it.

and my doctors think i need them. it's weird to me that there the company needs to make additional approval to cover the medicine they already decided to cover. if they don't want to cover wegovy, fine. but why second guess my doctor? why would they know better what i need?

My doctor prescribed me Ozempic, but my insurance company is very clear they only cover it for full diabetes, not pre diabetes. It may be a dumb policy but it is clearly the policy. I pay out of pocket. Your insurance company isn't saying you can't use Ozempic, they are just saying that they aren't covering it for you being overweight.

Part of this is because "pre-diabetes" is something of a public health scare tactic to get people to change their diet and exercise more. The diagnosis criteria are a little bit arbitrary.

Maybe it's a scare tactic but it prompted me to get Ozempic to lose weight (I exercised regularly anyway) and now my A1C levels are in the normal range. Better to do it now than wait until I had diabetes, even if I had to pay out of pocket.

[Anonymous]

Anonymous wrote:

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Anonymous wrote:Go to a real doctor?

I have been to two "real doctors". one prescribed ozempic and the other wegovy. thank you for your concern.

Then just pay for it yourself instead of trying to find a way to lie to insurance company.

I will pay for it but since I payed tens of thousands of dollars to insurance over years why not try to get some benefit from it once in a blue moon?

also, when did I lie to insurance? it is a fact that I am obese and that dieting has made me more obese. my blood work is what it is.

Excuses are the clever man's way of lying. We are all as smart as you are can see through your cleverness. You know that is not how insurance works, the goal is not to "use it" like it is expirable annual leave at work.

Ozempic is not prescribed for obesity, so you just told on yourself.

please stop making this into some kind of morality play. there is nothing moral about denying medicine to people who need them or making them jump over a bunch of meaningless hoops.

and yes, while at the technical level insurance does not work this way, on the moral level it is certainly not wrong to push to get a medicine my two doctors believe i need from an insurance i paid tens if not hundreds of thousand of dollars into.

the facts of my case are the following: i have prescriptions for both wegovy and ozempic. this is because i am obese and also, as i already put it, marginally pre-diabetic - outside of normal range but by only a very small number. ozempic coverage has been denied by my insurance and i don't know why yet. i am looking at my options. i have gotten several good suggestions for which I am very grateful.

is there any way to save on out of pocket costs, however slightly? i found some online coupons according to which I can get ozempic for around $900?

If you didn't want this to be a morality play, you wouldn't be giving all of these "reasons" why are not asking to break rules. You would just straight up say "how can I get around the rules" with pride.

NP. You need to just zip it. She isn’t breaking the rules. You don’t know what the f you are talking about. Wegovy is for obesity. OP is obese. A doctor prescribed Ozempic for off-label treatment. Perfectly appropriate. So can you stop harassing OP now snd seek some help? Signed - former health care fraud prosecutor.

And it's also perfectly appropriate for her carrier to deny coverage for the off label use, according to the terms of her plan.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Insurance companies decide what is covered. Not your doctor, OP. You can get a prescription, no one is stopping you. But you won’t have it covered so stop complaining, or else eat more bad food so you get full blown diabetes and then it will be covered.

insurance company does cover both ozempic and wegovy. so they already decided they would do it.

and my doctors think i need them. it's weird to me that there the company needs to make additional approval to cover the medicine they already decided to cover. if they don't want to cover wegovy, fine. but why second guess my doctor? why would they know better what i need?

My doctor prescribed me Ozempic, but my insurance company is very clear they only cover it for full diabetes, not pre diabetes. It may be a dumb policy but it is clearly the policy. I pay out of pocket. Your insurance company isn't saying you can't use Ozempic, they are just saying that they aren't covering it for you being overweight.

Part of this is because "pre-diabetes" is something of a public health scare tactic to get people to change their diet and exercise more. The diagnosis criteria are a little bit arbitrary.

The thing is OP didn’t even have “pre diabetes” as murky as THAT is. She said “marginal pre-diabetes.”

[Anonymous]

People, including Jeff who told us to MYOB on the front page of DCUM, seem to forget who pays for insurance. The money doesn't appear out of thin air, it's funded by the other people on your insurance plan. So OP getting her weight loss medicine covered by insurance means the rest of us have to pay for it.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Insurance companies decide what is covered. Not your doctor, OP. You can get a prescription, no one is stopping you. But you won’t have it covered so stop complaining, or else eat more bad food so you get full blown diabetes and then it will be covered.

insurance company does cover both ozempic and wegovy. so they already decided they would do it.

and my doctors think i need them. it's weird to me that there the company needs to make additional approval to cover the medicine they already decided to cover. if they don't want to cover wegovy, fine. but why second guess my doctor? why would they know better what i need?

My doctor prescribed me Ozempic, but my insurance company is very clear they only cover it for full diabetes, not pre diabetes. It may be a dumb policy but it is clearly the policy. I pay out of pocket. Your insurance company isn't saying you can't use Ozempic, they are just saying that they aren't covering it for you being overweight.

Part of this is because "pre-diabetes" is something of a public health scare tactic to get people to change their diet and exercise more. The diagnosis criteria are a little bit arbitrary.

Maybe it's a scare tactic but it prompted me to get Ozempic to lose weight (I exercised regularly anyway) and now my A1C levels are in the normal range. Better to do it now than wait until I had diabetes, even if I had to pay out of pocket.

OP evidently doesn’t want to do that.

[Anonymous]

Anonymous wrote:People, including Jeff who told us to MYOB on the front page of DCUM, seem to forget who pays for insurance. The money doesn't appear out of thin air, it's funded by the other people on your insurance plan. So OP getting her weight loss medicine covered by insurance means the rest of us have to pay for it.

And to take this attitude, don’t coming crying to the rest of us when your health issues hit. Because they will. You may not need THIS medicine or have THIS medical problem but you will have something else.

[Anonymous]

Anonymous wrote:People, including Jeff who told us to MYOB on the front page of DCUM, seem to forget who pays for insurance. The money doesn't appear out of thin air, it's funded by the other people on your insurance plan. So OP getting her weight loss medicine covered by insurance means the rest of us have to pay for it.

You're being penny wise and pound foolish. The medicine costs less than the complications that arise when weight loss is not addressed. Paying a little now saves the insurance pool a lot later.

[Anonymous]

Anonymous wrote:

Anonymous wrote:People, including Jeff who told us to MYOB on the front page of DCUM, seem to forget who pays for insurance. The money doesn't appear out of thin air, it's funded by the other people on your insurance plan. So OP getting her weight loss medicine covered by insurance means the rest of us have to pay for it.

You're being penny wise and pound foolish. The medicine costs less than the complications that arise when weight loss is not addressed. Paying a little now saves the insurance pool a lot later.

Apparently, the actuarial analysis used by the insurance companies, which I'm guessing is more sophisticated than your guess, disagrees. Which do you think is correct?

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:People, including Jeff who told us to MYOB on the front page of DCUM, seem to forget who pays for insurance. The money doesn't appear out of thin air, it's funded by the other people on your insurance plan. So OP getting her weight loss medicine covered by insurance means the rest of us have to pay for it.

You're being penny wise and pound foolish. The medicine costs less than the complications that arise when weight loss is not addressed. Paying a little now saves the insurance pool a lot later.

Apparently, the actuarial analysis used by the insurance companies, which I'm guessing is more sophisticated than your guess, disagrees. Which do you think is correct?

they are not doing actuarial analysis to decide coverage. this is not life insurance.