Insurance won't pay anymore :(

Hong Kong Yanpep International
Only got approved once diabetes entered the picture for me. Could be that. Or maybe they've decided your weight doesn't meet whatever threshold they require.
 
She would've preferred a different approach, but insurance wouldn't cover it that way. So I ended up bumping the dose every month until I hit the max. Did fix my A1C, though I suspect I'd have lost more weight if it went the way my doctor originally intended.
 
Appreciate the response! Was actually looking into that route, but unfortunately my insurance won't cover it when it's coded for weight loss, and paying out of pocket monthly gets expensive fast when I've still got over 100 pounds to go.
 
Because the second your BMI drops enough, they're off the hook for paying, and you'll lose fastest on the higher dose anyway. Figuring out the titrate-down and maintenance plan is on you though. Insurance is only looking out for their own interest.
 
Lost count of how many times I got told losing 15% of my body weight would fix it, only to hit that goal and have the target quietly shift another 15%. Dropped 100 pounds, landed squarely in the healthy range for both weight and body composition, guess what though, still diabetic. Kept it all off, and this same doctor wanted another 10% loss... from where exactly?! Reached my limit and switched providers two years back. New doctor tried different oral medications plus alternate insulin brands. Made those swaps but still didn't move the needle enough, so mounjaro finally got prescribed. Starting it next week actually. Insurance approved full coverage this past Friday, expecting it to arrive any day.

The generic 'just lose weight' advice never got me anywhere. Some doctors treat it as their only answer. Feels like their go-to script.
 
My coverage got pulled (I've got type 1 diabetes). Filed an appeal and the insurer denied it. Took it to the state next (Pennsylvania) and actually won. An AI assistant helped me put together all the paperwork, made the whole thing surprisingly manageable. Submitted my pump data showing my A1c dropped from 8.5 down to 6.2 while on this medication. Won at the state level and it's back to being covered now.
 
Stopped once insurance quit covering it. Put some weight back on, I do exercise daily but wasn't great about walking through the winter! Didn't want to just quit the medication outright either, terrible insurance situation. So they re-approved coverage after a ten pound gain, but only for the daily liraglutide injections. That's done nothing for me. Walking more now on top of still exercising, hitting my protein and fiber goals, and still finding myself wanting more food on top of it. Cravings and food noise are back in full force and my willpower around emotional eating just isn't strong enough. My doctor just resubmitted the pre-approval paperwork for Wegovy since I've gained a few more pounds again, and also brought up Zepbound as an option. She just wasn't confident insurance would cover that one without trying Wegovy first, assuming they'd even cover Wegovy. Can't afford either one without insurance backing it.
 
Just talked about this with my doctor. I'm 1.5 years into M at the top dose (15), down over 100 lbs with 10 more to reach goal. My doc's advice was to remain on M for good because the weight comes back if I stop, and I've had no complications with it. With Medicare Supplemental I only pay the 2k out-of-pocket max and then it's free for me, which normally happens around August 1st. Staying on medication indefinitely is depressing, but new medical tech may show up, so I doubt it'll be forever. Worrying about the future doesn't help me, I just focus on what's best for me now. Meaning I keep taking M until my doc or I see a reason to change.
 
sourdough_readerog76 Interesting. That's the same reasoning my zepbound for weight loss got denied on. They insisted I first go through a few other options that didn't work. So my doc said your latest glucose reading was high, let's try that, and submitted Mounjaro for T2D, which needed PA. Once she attached my bloodwork, approval came through.
 
My Wegovy got covered for weight alone, likely the toughest coverage category. A minimum starting BMI had to be met, and my doctor had to attest that this medication served as a substitute for the costlier procedure of bariatric surgery. The toughest part: they demanded I trial and fail cheaper medications (I'd already spent over a year on Wegovy and lost over 100 pounds by the time the criteria changed) but because of contraindications with those and my need to stay on the med for clinical stability, she got it covered. Approval needed 3 attempts, the last with a formal appeal. I'd guess sleep apnea gets approved a bit more easily, though I can't speak from experience.
 
I work in insurance, so this comes from that angle. Mounjaro coverage for diabetes is usually included in most employer plans, but plenty are tightening up, wanting lab proof rather than just a doctor's note. Some plans are moving to annual reauthorization, so resubmitting old A1C numbers might not cut it. Many doctors aren't digging into each plan's fine print, some probably avoid extra bloodwork just to keep coverage simple. It's frustrating that PBMs charge employers two or three times what direct purchase would cost. As more employers drop weight-loss-only coverage, patients and doctors lean on Mounjaro as a workaround since it's technically the diabetes version. Worth remembering, Mounjaro's for diabetics, Zepbound for non-diabetic use. Call your Rx plan and ask what's covered.
 
My A1C only improved because of this medication in the first place. Stopping would just send it climbing right back up. Ive stayed solidly under the diabetes threshold going on well past a year now, with zero issues from my insurance, still covered completely.
 
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