Let me explain with my current situation. I am 22 F and I currently weigh 305lbs.
I am obese. Morbidly obese.
Even though I have been trying for 5 years at this point to lose the weight on my own. Eat healthier, eat more fruits and veggies, cut out excess sugar, walk more, exercise more, the whole kit and caboodle.
But I still am not losing the weight. I am still very fat. And I am worried that it will cause very serious health problems.
So I talked with my doctor and she told me “We need to get you on a weight loss medication. Let’s try Ozempic”.
But my insurance told us that they don’t think I need the Ozempic so they won’t pay for it.
So we tried Wegovy and Mounjaro. But my insurance still rejected our requests.
They’re saying because I am young, and I am a diabetic with good numbers, I dont need the weight loss meds and I can just lose the weight naturally.
But ive been trying to and it hasn’t been working. So that’s why my doctor prescribed me the weight loss med.
Why is this allowed? Why is it that your insurance can deny you a medication, even if your doctor says you need it?
This is what pushed Luigi to merc one of them
What do you mean, Luigi was at my place playing xbox games when that guy got killed.
Can confirm. I was playing with both of them online, and Luigi and I were making lewd comments about lemmyng’s mom.
That was so rude, but also hilarious. It was a big lobby that night, but Luigi was really keeping everyone chill.
yep, I was there too.
Allegedly ☝️
It’s quite simple:
They are money-grubbing assholes in an unregulated industry. Their goal is to make as much money as possible while hurting as many people as possible. Because if they hurt people, they can take their money and provide no service.
It’s legal because the government won’t make it illegal.
They argue that they are preventing waste and fraud by holding doctors accountable. Like “oh if we didn’t have this power then doctors would order so many unnecessary tests and prescriptions”
(Not defending them, just sharing what they say)
Yeah, and what they say is bullshit. Doctors prescribe the medicine people need.
They don’t care about fraud. They care about their profits. We shouldn’t repeat their excuses like that.
If that was the case we’d have one of the most efficient medical systems in the world instead of one of the least
They can’t, they can only deny coverage for it. You can still get it paying for it yourself.
Yeah, paying $200+ a week for a shot. In this economy?
I don’t know anyone who has that kind of money
imagine trying to get approval for biologics, which can thousands a month.
The intended goal of conservative voters is to ignore your plight and they’d like you to die off screen.
Health Insurance CEO
I just went through this battle myself. And my insurance even approved it, but I’m traveling overseas for two months and even though they tell me my benefit covers a “vacation override” they wouldn’t approve it.
I asked the pharmacy how much it would cost to pay out of pocket. $1300 for 4 weeks, so $2600 to cover my trip.
Luckily my Dr was able to give me “samples” to get me through my trip.
Also, another thing that I learned in the past year. What your insurance will cover and how much they’ll cover changes depending on your history.
Spend a three day weekend in the ER/ICU and suddenly I DO need Ozempic and they’re giving me thousands of dollars worth of CGMs for free.
It’s all a cost/benefit analysis for them.
I’m not saying it’s right, I’m just saying it’s so.
Here in NZ it’s less than usd $300 a month full cost, but usually funded by the govt.
Not always. Sometimes, companies won’t sell it to you if your insurance has denied it. They may say it’s because they don’t believe you can afford it.
Monied interests have crafted a legal system that benefits them, not you.
I hate that this is happening to you.
Darknet Markets are booming with semaglutides because of capitalism’s greed.
This guy is so photogenic, it’s insane
he bulked up in jail apparently too.
My wife was prescribed one of those for her diabetes, and the insurance company STILL wouldn’t cover a dime. She was able to find a coupon for a three month supply for $350.
And see, that’s what my problem was
Yes, I am technically a type-2 diabetic, but i am a diabetic with good numbers, so my insurance is saying "oh we wont pay for those meds. You don’t need it."🙄😒
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Three months for 350 is pretty good, here it’s 500 a month.
Because the filthy rich don’t care if anyone dies.
They care if a rich person dies. My friend Luigi proved that.
Allegedly. Could have been anyone. More people had a motive than would fit into a police database.
Capitalism and actuarial science. Their models likely show that you are still young enough for them to keep you fat for a few years while the cost of GLP1s go down.
The reason is that doctors and pharmaceutical companies are also for profit, meaning they make money selling you treatments. This puts them in a position to use your condition to exploit both you and the company. The insurance company is balancing the cost of your preferred treatment versus the cost of other treatment and the benefits. You can work with your doctor to build a documented record of attempting to lose weight- see a nutritionist, start seeing a therapist for your food addiction, start going to weight loss meetings, exercise therapy for the morbidly obese, etc. These will also be helpful by themselves, because those drugs are only temporary. Like weight loss surgery, people regain the weight when they don’t do the work to address the underlying issue.
You can get wegovy 28-day of the auto injectors through Amazon pharmacy for $200 a month without insurance. It still requires a prescription, but it sounds like you have that.
Obviously it would be better if your insurance would cover it, but $200 a month is better than the $600 a month some people are paying for ozempic/etc.
When signing up for insurance, you’ll want to check their approved medications. My wife was prescribed mounjaro for her diabetes, but most of the insurance plans we looked at didn’t have it listed as one of their approved medicines. It was one of the largest factors in deciding which insurance we needed to go with.
apparently you can use coupons for the pharmacy in amazon to lower the price evenmore. i wonder of goodrx works on it.
Clown ass country where we need coupons for medicine
Because Fuck You, that’s why.
Had the same experience. I ended up having my doctor write a prescription for wegovy pills and am just paying $200 out of pocket. I figure I’m at least breaking even by eating less. Only been a month so far.
The insurance company is going to have a doctor who said you don’t need it. They will try to hide who that doctor is, specifically what their NPI is, which can be used to personally identify the doctor who made the medical judgement against your doctor’s without having to provide further explanation than they’ve already given. Depending where you are they may have to provide more information when directly asked for specific evidences, or will suddenly change their rejection on the claim with a letter from an attorney asking for specific details in writing. They know hiring an attorney is expensive and bank on people not advocating for their rights & people with severe medical issues not being able to afford to.
And lastly a video of a surgeon being denied the NPI of the insurance’s doctors who are likely breaking the law hiding behind the idea that insurance doctors are so hated they need to hide their identity even from other doctors to prevent reprisal. She was blacklisted from United claims for this video and others like it.
This is the lore. I haven’t heard from anybody trying it, I hope OP will make the attempt and report back.
Isn’t the insurance approving the medication/procedure only after being asked for proof the denial was legally obtained evidence that the denial was illegal, and reason enough for a lawsuit?
The insurance company is going to have a doctor who said you don’t need it.
To add on to this, my psychologist told me that he’s had antipsychotic meds denied by a urologist before, because the insurance companies often don’t actually care what field the doctor is in. All they care about is getting to say “a doctor” reviewed it.
I have a relative who is a doctor. Had a claim denied once from someone that was not a doctor. Next: denied by someone not actively practicing in the field. Then denied by a doctor with no experience in that specialty. Only after all of that was it approved. They’ve also been picky about order of operations, such as not covering an MRI because there wasn’t also an order for a CT.
And you can leverage that in your appeal letter.
Especially when you have a pissy provider who doesn’t like being told “no.”
then they have teams to review the first insurance agent approved your medications, and sometimes a team to review that teams decision of said medication. they will do this til you give up.
The insurance companies want to make money.
There are no (enforced) laws prohibiting this behavior.
Very few insurance company decision makers are murdered in the street.
Change one or more of these, and you’ll get better results.
Mounjaro and Ozempic both have savings cards you can sign up for on their respective websites, as long as you aren’t on government insurance.
I had the same issue last year, my A1C was 6.9 and insurance denied coverage. I got the savings card from Lilly, had my doctor call in the script and BAM! 25USD for 12 weeks of Mounjaro.
I didn’t even need a prior authorization anymore. Apparently results may vary, but I got lucky. Try them both if needed. Stay vigilant!
they recently stopped covering glp-1 and similar for state subsidized healthcare, seems to coincide with it being lobbied against recently in congress.
I am on government insurance.
Eat healthier, eat more fruits and veggies, cut out excess sugar, walk more, exercise more, the whole kit and caboodle.
Not to say you should be denied prescription coverage, but that is not the whole kit and caboodle. Weight loss results from consuming less calories; specifically, less than you are burning. You can lose weight on a completely unhealthy diet and without any extra effort to exercise.
Yep, this. I’m like 130 lbs and I literally sit around all day and I eat garbage. But just a little garbage.
Sadly there are some people i know who gain enough to look unhealthy if they dont eat a strict healthy vegan diet. And its easily to see in some cases. A friend of mine was very annoyed when she only got compliments after such rigorous effort. At that time her unhealtiest snack was dried strawberries.
On the other spectrum is me who cant gain any weight how matter what and how much i eat (cant even donate blood ;.;)
Bodies are VERY different and there are extremes where only meds can help and i think OP is one of them
she must be dehydrated if she eats “freeze dried strawberries”
She definetly hydrated helself properly with those 2L/Day bottles
True, and it could be easier for them to keep weight on, but CICO is a very basic science and will work if one keeps to it.
What a pointless post.
If my alternative would be 200$ per week, I’d take eating less as a solution.
And depressed people can save money by just smiling more!
My first reaction would be to say not the same thing, but then I remembered we’ve had studies recently that have confirmed that depression can genuinely be helped by leaving the house and touching grass.
But still not the same thing compared to depression, unless you have some eating related disorder or medical issue, the vast majority don’t and historically never have. The obseity epidemic is caused by caloric density creeping up in ultra processed foods, which already tells you everything you need to know, tricking people into thinking they eat a normal amount when they most definitely don’t.
The fact that this food is almost like a drug for some brains combined with the fact that some bodies struggle more than others with burning calories can make it more difficult at first for people but given difficult circumstances like having to pay 200$ per week to do something about it, there is always the free alternative. The difficulty in this case is more akin to quitting smoking or coffee. No one said it’s easy, but most could do it if they set their minds on it.
On a less brute force but not free path I would spend a fraction of that money on a dietician that can monitor my intake and make recommendations. At least that way there’s external support and motivation. I found they are like 100-200$ per month so an 8th to a quarter of the ozempic price.
While CICO is universally true, it doesn’t account for a few other factors. For instance, gut microbiome. Gut flora has a strong affect on cravings. Also mental and emotional health also affect self control and regulation. Food “science” has created craving
monstrositiessnacks that are as addictive as cigarettes. Personal health issues like PCOS and thyroid dysfunction will affect how many calories are consumed by the body and how those calories are used within the body.So yes, eat less and lose weight. Sure. Some people can lose weight eating junk. For others it creates a reward cascade in the brain that leads to overeating. Just eat less. For some that’s as practical as telling a lifelong smoker to give up the habit. And that’s why medical alternatives to self control exist, but aren’t successful without addressing the root cause of the obesity.
All those behavior cycles and feedback mechanisms are also literally what these GPL drugs suppress.
It’s like anxiety meds for someone who has diabilitating anxiety to just relax. Or more commonly telling the clinically depressed to just smile more.
Telling someone it’s a personal failing only fuels the feedback mechanism.
Medications exist because they stop the biological feedback loops.
Exactly!
