Insurance hassle, AGAIN!

Donut_Side

Donut_Side

Member
I'm so frustrated. Started on tirzepatide in spring 2025 and lost about 65 pounds in maybe 7 months. I'm holding steady around 170. Just about to lower my dose to 7.5mg every nine days and BAM, insurance now needs a pre-auth. They NEVER asked before. My doc sent all they asked for and they rejected it.

Now they're saying it's because my doc didn't have me try other diabetes meds first. I went straight to tirzepatide. My A1C was high enough (6.6) to qualify then, and I'm healthier now. But, they want me on something else FIRST. I'm trying to get my doc to give me a script for metformin for a month, then try the tirzepatide again and see if they approve it.

Anyone else dealt with this? These pharmacy benefit managers are a nightmare... I haven't had bloodwork since last spring. Getting some done this week or next. What's the worst that can happen? They deny me 'cause my A1C is good now? They already denied me! At least I can show it was working.

Thoughts?
 
They shouldn't deny you due to a better A1C. Diabetes is a lifetime thing. Sounds like they're trying to wear you down so you give up. Don't do it. If you have problems with that metformin, tell them ASAP it's giving you stomach issues or isn't helping your blood sugar, etc. Metformin has issues for a lot of people. I know I did!

They're hoping you'll quit.
 
My out-of-pocket cost here in Texas is $1,400. My insurance says I need pre-authorization, and they stop covering it after two months at any dose. They wouldn't cover my 2.5 dose, only if I went to 5mg. I wanted to stay on 2.5 as long as it worked. My cost with coverage is $160. It feels like the insurance is telling my doctor how to practice medicine. I am diabetic. My A1C was 9 when I began, now it's 6. Started in December 2026. I was told I'd need this long-term. Two weeks trying to fix this mess. How can we get the right treatment when insurance is fighting us? All the time spent by me, the pharmacy, and my doctor is impacting my life!
 
Anyone from other countries must be confused. I pay maybe $200 a month. We have centralized healthcare, so we have huge negotiating power. You're all on your own, trying to fight for your health when the insurance companies might deny your medicine. Why was Obamacare so frightening? Genuine question from Europe.
 
Just getting a metformin prescription (didn't even take it!) was enough to get my MJ approved. It's been a couple years, no new PA needed. Fingers crossed!
 
I've been on Mounjaro for a while, lost a lot of weight too. Switching to Medicare soon. My new Wellcare plan needs Prior Auth for Mounjaro. From Reddit, Wellcare wants an A1C over 7 and proof of step therapy (2+ drugs), which I'm gathering for my doctor. Old notes show Metformin, Glipizide and Januvia with A1C over 7, plus side effects (should document those). Since starting Mounjaro, I'm between 6.3 and 6.8, so hopefully they approve it. My employer plan via CVS/Caremark never pushed back.

Just a month or two on pills probably won't work. They'll want to see A1C at 3-6 month intervals with cheaper meds, based on forums. A1C measures over 3 months. Glipizide & Metformin are Tier 1 generics, Januvia, Jardiance & Janumet are Tier 3, and Mounjaro is pricier...

I've never seen an endocrinologist, just my PCPs.

Did you or your employer change Pharmacy Benefit Managers (CVSCaremark/UnitedHealthcare/ExpressScripts)?

"Continuity of care" might help, but they'll likely want to see med step therapy and A1C results over 6+ months. My commercial plan pushed for cost cuts (mandated CVS only and 90 days, mail-order, etc.), but this wasn't an issue, because my doctor had all the records already.

If everything fails...

Wegovy (Ozempic) is $150/month for the 1.5 mg and 4 mg doses (after April 2026), and $300/month for the 9 mg and 25 mg doses.

Zepbound (Mounjaro) is ~$350/month

Much cheaper than the $1000-1200/month they were priced at. I liked Mounjaro better than Ozempic.
 
Have your doctor call. Mine got tired of the denials after me being on it for a while. I don't know what she said, but it worked. Next day, text saying my prescription was ready then a week later a letter saying it was approved for a year.
 
I used Metformin for maybe 2 months and it made me so sick, horrible stomach problems... and did nothing for my blood sugar. It's cheap, so insurance pushes it. They don't want to pay for what you need for life. I don't have insurance, so I use Telemed and compounded tirzepatide. It's great! My blood sugar went from 300+ to 90-110 daily, blood pressure is perfect. There are lots of issues with Metformin. This is just my experience.
 
Same here in Germany. It's for diabetes, but once you're at 6.3, it's a "lifestyle drug". Only high-risk patients, like retinopathy, get it covered. My doctor said my numbers are too good and we'll wean me soon.

I started last fall. I lost 32 pounds and I'm devastated.
 
My A1C is 5.1, has been for 2 years, and I've never been denied. I get labs every 3-4 months. They might want updated labs.
 
I saw a doctor on Reddit recommending a glucose tolerance test to get a diabetes diagnosis. Apparently, it's more sensitive than the regular A1C test. Could be a way to get approved if your A1C is borderline. Just be aware that a diabetes diagnosis stays on your record forever.
 
Yeah, I saw that Reddit post, too, Scale_Ready. Seems kinda shady, but honestly, these insurance companies are such a pain. If you need the med, you need it. Playing the game might be the only way to win.
 
Scale_Ready said:
I saw a doctor on Reddit recommending a glucose tolerance test to get a diabetes diagnosis. Apparently, it's more sensitive than the regular A1C test. Could be a way to get approved if your A1C is borderline. Just be aware that a diabetes diagnosis stays on your record forever.
Click to expand...

Interesting... I'll look into that GTT test. Thanks!
 
If you're on Medicaid, it might be worth getting the prescription anyway.
Eddie said:
Just getting a metformin prescription (didn't even take it!) was enough to get my MJ approved. It's been a couple years, no new PA needed. Fingers crossed!
Click to expand...
Some folks get approved even when they didn't think they would. The worst they can say is no, right? Also, check if they cover Wegovy instead, since that's specifically for weight loss.
 
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