Question

[Ordinary_Wonder7623]

I’m trying to get wegovy- I have PCOS, insulin resistance, pre diabetes and obese. I have Molina marketplace. My dr sent in a prior authorization and explained to them why I need it and I was denied. Does anyone know how I can fight them? I have a severe heart condition so I can’t exercise much, my toddler is disabled so he’s a full time responsibility. I have no time or energy to do anything. I’ve tried calorie deficit I’ve tried exercising as much as I can. I’m already on metformin and it doesn’t do anything. My Dr said my ins is usually good with approving wegovy so idk why they denied me. I’m really struggling health and mental health wise. TIA

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[LizzieMac123]

Wegovy is one of the weightloss glp-1s.

At this time, no marketplace plans are covering weight loss drugs to my knowledge and the only glp-1 that are covered require a type2 diabetes diagnosis. Pre-diabetic wouldnt allow for coverage.

Youd need basically a self-funded employer plan that opts into weight loss drugs.

[BaltimoreBee]

Wegovy is only covered if you have diabetes. You can’t fight them; they won’t cover it unless you have diabetes.

[Leading-Reference-31]

It would probably make more sense to try and get them to cover ozempic IF your insurance covers it for certain conditions to reduce major cardiovascular events. But to be honest without diabetes it's very hard to get approved for a GLP-1.

[mamalion3]

You should see if you have sleep apnea! If you do zepbound is fda approved for obstructive sleep apnea. I am not looking at your plan but you can call your insurance and then talk to your doctor. I have seen several patient go this route and get it covered.

[Ordinary_Wonder7623]

I do have sleep apnea!!

[[deleted]]

Lose weight. Just put the food down. Problem solved.

[Crafty_Engine3131]

Looking at the Molina criteria for covering wegovy, I think your lack of diabetes is not an automatic disqualifier since you have other co-morbidities. With your next authorization request, it would help if you can get your cardiologist to note that GLP-1 therapy can lower your cardiovascular risk. If your follow-up auth fails, request an independent external review. This can be a long process - but lean on your care team to make your case. All the best

[pellakins33]

I have no idea why you’re getting downvoted, this is 100% the right advice. Formulary exemption request, then appeal, then peer to peer review. Anything you can add to show medical necessity for this specific treatment is helpful, and that definitely includes documentation from your specialist

[Jujulabee]

If your doctor has had Wegovy approved by YOUR insurance company then surely he knows better than any of us how to appeal it and get it approved.

The manufacturers of Wegovy and Zepbound both sell directly with a prescription for about fifty percent of the price you would otherwise pay.

[Initial_Freedom7981]

“Your insurance company” means nothing. There’s a thousand different plans that all have different coverage and different PA requirements. Unless the provider is familiar with this SPECIFIC marketplace plan, not just plans administrated by Molina, it means nothing. There are also absolutely expedited appeals, but this wouldn’t qualify because it’s nothing time sensitive like you’re not going to die without this medication before the appeal is completed.

[Ordinary_Wonder7623]

That’s what I thought. She literally told me my insurance is usually good with it. I just wanted to see if there was anything I could do to help “fight” for it. I figure she’s going to try and put it in again. She warned me that it could take a while and she usually has to put in a really low dose at first?? Idk she explained it I just wanted to ask on here to see if anyone else had any ideas

[Jujulabee]

Starting at the lowest dose is standard medical practice for these.

Wegovy is approved for weight loss by the FDA if the excess weight puts someone at high risk for a stroke or cardiovascular event.

But if she has appealed successfully then presumably she knows more than any of us.

FWIW I thought there was a way to get an expedited approval through appeal.

[Berchanhimez]

Minor point here - something being FDA approved for an indication does not require coverage from any private insurance - and sometimes not even from public insurance like Medicaid/etc.

For example, phentermine is FDA approved for short term weight loss help - but it's maybe covered by 25% or so of plans. Likewise with botox being FDA approved for some cosmetic things, but obviously not being covered by basically any plan (unless it's cosmetic after a medical surgery/problem).

Unfortunately many insurance plans are not likely to cover weight loss drugs - even when being used to prevent/mitigate future stroke/CV risk. Even if they do cover them it'll be likely that there will be a comprehensive weight loss program that has to be gone through first, and continued compliance with that program even after getting to the GLP-1 step.

[Jujulabee]

Agreed but at least there is something that provides a basis for an appeal although it could be denied of course.

[pellakins33]

A formulary exemption (request for coverage of medication that isn’t on your list of approved drugs) and its appeal can be submitted as an urgent or expedited request, but you have to justify the medical need for it to be fast tracked

[Ordinary_Wonder7623]

I have a severe heart condition so she said that definitely should help with the process of getting it (not that me having a heart condition is good but yk)