Insurance won't pay anymore :(

B

Bio_FWIW

Active member
My husband's prescription was blocked because he didn't shed sufficient pounds, even though his blood sugar is way better and he did lose *some*. His doctor wants him to keep trying. Has anyone else had this happen? Were you able to switch meds and still have it covered?

I should add - we're on the same plan, and I've been on maintenance for two years with zero issues.
 
Yeah, sadly it's pretty common. Most insurance companies want to see you drop at least 5% of your weight within the first six months to keep covering it.

Some folks just don't respond, or they don't change their lifestyle. You really can eat right through these meds if you aren't careful. Insurance isn't going to keep paying if it's not working, from their perspective.
 
Isn't it wonderful that we have a working solution for the most widespread health problem caused by our lifestyles, but it's only available to the wealthy?
 
Our 'premium' insurance decided last year that GLP-1s are a no-go for everyone. My hubby has practically every risk factor going – high blood pressure, cholesterol, apnea, pre-diabetes. Denied, appealed, doctors swore he was perfect. Still no.

Just wanted to say I feel your pain. This stinks.
 
I've actually never heard of that specific rule, but insurance companies are always finding ways to avoid paying. Get the denial in writing, with their exact coverage requirements, and use that for your appeal. In the meantime, telehealth is still an option – you can get it for about $150 a month, any dose. But free is much better if you can manage it through insurance.
 
That insurance threshold situation is super frustrating, and I'm sorry you're dealing with it. The annoying truth is that most plans demand a certain percentage of weight loss (usually 5-10%) within a certain time, and if you're close but not there, it can come down to water weight, muscle gain, or just a bad day for the scale. A few things to try before giving up:

* Request a formal appeal and ask your doctor to document any improvements in comorbidities (blood pressure, blood sugar, cholesterol) – sometimes they'll budge on medical necessity.
* See if they'll grant a 90-day extension; some plans allow it.

On the practical side, stay hydrated! Semaglutide can mess with your fluid balance and cause bloating, which affects the scale. Electrolytes helped me a lot with that; I use unflavored drops to avoid added sugar. Document everything in writing, get your doctor to advocate, and look into patient assistance programs if you're denied. People have won appeals, so don't give up yet.
 
Bio_FWIW said:
My husband's prescription was blocked because he didn't shed sufficient pounds, even though his blood sugar is way better and he did lose *some*. His doctor wants him to keep trying...
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That's really infuriating. It should be about overall health, not just the number on the scale.
 
I'm so scared of this happening to me! I've lost about 75 pounds and this medication has changed my life. I don't know what I'll do if they stop covering it.
 
Hank_25 said:
I'm so scared of this happening to me! I've lost about 75 pounds and this medication has changed my life. I don't know what I'll do if they stop covering it.
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I totally get that fear! After our denial, my husband and I looked into cheaper options. It's tough, but don't panic yet. There are options, even if they aren't ideal. Keep fighting for coverage!
 
Congrats on the weight loss, @Hank_25! That's amazing! Hopefully, your insurance will continue to cover it. If not, definitely look into those manufacturer programs and telehealth options.
 
Self-pay often undercuts the copay once you factor in compounded - the denial is frustrating but access still exists.
 
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