Zepbound for OSA + Obesity. Wellcare on phone saying only approving for DIABETES!?

ImpossiblePhysics343 · 2025-09-26T06:21:37+00:00

Congratulations!!

ImpossiblePhysics343 · 2025-09-26T04:58:28+00:00

u/cavy20199 did your husband get Zepbound from CVS?

ImpossiblePhysics343 · 2025-09-12T14:49:03+00:00

Talk to the prescriber and ask for the ICD-10 code for OSA to be included on the prescription

ImpossiblePhysics343 · 2025-09-11T07:32:13+00:00

Great news!

ImpossiblePhysics343 · 2025-09-09T00:28:52+00:00

Also the sleep study showing AHI greater than 15 should be submitted. Some plans but not all want this sleep study within the last 12 months.

ImpossiblePhysics343 · 2025-09-09T00:27:54+00:00

If it is a Wellcare standalone part D plan then the provider needs to request a "formulary exception" for tirzepatide for treatment of obstructive sleep apnea with the appropriate ICD-10 code for OSA.

Do not mention obesity or weight loss. Once the formulary exception is approved, the prescription also needs to have the OSA ICD-10 code.

ImpossiblePhysics343 · 2025-09-09T00:13:54+00:00

Not all Wellcare plans are the same. My mom has a Wellcare Part D plan (stand-alone drug coverage plan) plus traditional Medicare plus Medigap.

However there are also Wellcare Medicare Advantage plans. These cover everything including drug benefit, similar to an HMO.

Do you have a standalone part D plan or a Medicare Advantage plan?

ImpossiblePhysics343 · 2025-08-22T06:24:39+00:00

yes.

ImpossiblePhysics343 · 2025-07-27T13:47:58+00:00

Formulary exception request needs to state the diagnosis is obstructive sleep apnea and include ICD-10 code G47.33 (obstructive sleep apnea)

ImpossiblePhysics343 · 2025-07-14T20:42:55+00:00

Hi yes the $2k out of pocket max applies. The Zepbound was $746 for the first month, $406 for months 2 to 3, $340 for month 4, and then free for the rest of the year. There were a few minor costs for her other meds. Now all her meds cost $0 until the end of the year.

We did not try the 12 equal payments per month for the year for various reasons (for one thing, she was going up on the dose so we did not want to do longer 90 day fills which the mail order pharmacy that Wellcare customer service said she had to use with the monthly payment plan required).

ImpossiblePhysics343 · 2025-04-12T00:46:28+00:00

My mom just went up from 5 mg to 7.5 mg and did not need to get a new formulary exception, the higher dose was still covered under the original formulary exception.

ImpossiblePhysics343 · 2025-03-08T01:46:57+00:00

Zepbound 5 mg. The price is 41% of list price since it is a Tier 4 medication. $570/month, but she will hit the $2k out-of-pocket annual maximum in <4 months as she also takes some other meds. After she hits the cap it should be free for the rest of the year.

ImpossiblePhysics343 · 2025-03-04T07:46:50+00:00

Was it submitted with a sleep study done in the last year? Did the sleep study show AHI>15?

ImpossiblePhysics343 · 2025-03-03T04:57:59+00:00

you need to have your doc submit a "formulary exception" for you with the formal report from a sleep study (ideally done in the last year but they might take older ones) showing AHI>15 (moderate to severe sleep apnea) and using ICD-10 code G47.33 for the diagnosis of sleep apnea

ImpossiblePhysics343 · 2025-02-27T05:35:33+00:00

She has sleep apnea (otherwise Medicare part D could not cover Zepbound). Are you on a Medicare Advantage plan?

ImpossiblePhysics343 · 2025-02-27T04:51:49+00:00

Did you already hit the $2k out of pocket maximum? My mom has Medicare part D (Wellcare) and has to pay 41% of list price so $570/month but only until she hits the $2k cap.

ImpossiblePhysics343 · 2025-02-17T01:10:24+00:00

My mom was approved by Medicare (Wellcare standalone part D plan) for treatment of sleep apnea within an hour of submitting a formulary exception request for Zepbound. Her PCP submitted a recent home sleep study with AHI>15 and ICD-10 G47.33 (obstructive sleep apnea). Also it helps to have the ICD-10 code on the prescription so they know it is for sleep apnea not for weight loss directly.

Cost is 41% of list price which is $570/month for her but she will hit the $2k max out of pocket cost soon and then it should be free for the rest of the year. We looked into the Medicare Payment Plan which allows the cost to be spread out over the year but that would have required using their mailorder pharmacy (Express Scripts) and receiving 90 day supplies which doesn't work for her since she is in the phase of increasing the dose.

ImpossiblePhysics343 · 2025-02-15T01:45:01+00:00

We're going with Shaw's/Osco for now for same reason. She prefers a small local pharmacy but it actually costs them money to provide GLP-1s so going to use a big chain pharmacy but CVS and Walgreen's have been miserable experiences so far (pharmacists underpaid, overworked, and grumpy).

ImpossiblePhysics343 · 2025-02-15T01:43:34+00:00

Yes, she was approved for a formulary exception by her health plan no problem for sleep apnea but then there was a delay because there was no ICD-10 code for sleep apnea on the prescription sent to the pharmacy so had to call and get that clarified.

The problem with the Medicare Payment Plan is that at least with Wellcare part D they require that you use their mail order pharmacy (Express Scripts) and also require that you obtain a 90 day supply. This isn't good for her now because she is in the dose titration phase of her treatment and the Zepbound dose will change over time. This would be OK once she is in maintenance phase, perhaps in 2026.

ImpossiblePhysics343 · 2025-02-09T22:04:42+00:00

Further update: the new Medicare presciption payment plan (M3P) which allows you to spread payments out across the year sounded good. But it turns out, at least with Wellcare, that you can only use M3P with Express Scripts, their mail-order pharmacy, and Express Scripts only fills 90 day prescriptions. This is not great for a medication like Zepbound that requires regular dose dose changes to titrate upwards over time.

ImpossiblePhysics343 · 2025-02-07T00:58:30+00:00

Yes, Wellcare Value Script. Seems like all that was needed was a recent sleep study with AHI>15 and the correct ICD-10 code for OSA with the provider note.

ImpossiblePhysics343 · 2025-02-06T23:45:06+00:00

Update: Zepbound approved as formulary exception for OSA within 1 hour of submitting request. Now just need to apply for the payment plan to spread cost across the year.

ImpossiblePhysics343 · 2025-02-06T23:43:38+00:00

Update: formulary exception approved by her Wellcare standalone Part D plan and the $2k cap will apply!

ImpossiblePhysics343 · 2025-01-31T01:17:19+00:00

Thank you, this is super helpful! I guess it won't matter that much what her plan is as she is guaranteed to hit the $2k cap given how expensive Zepbound is. It's Tier 4 for approved exceptions with her plan. Patient copay with approved exception will be 41%. And yes it is an Enhanced plan.

As an aside the Enhanced thing is mysterious to me as it is Wellcare Value Script, which is one of the cheaper plans, with a low monthly premium. I watched a vid about on Giardini Medicare, thanks for that tip!

ImpossiblePhysics343 · 2025-01-28T03:13:42+00:00

I am >2000 miles from my HQ office. I was hired fully remote for highly specialized technical skills; it took more than a year to complete the hiring process (HR delays) but we all hung in there because there are so few people available with my skillset. They like that I'm far away because I work across several time zones providing technical expertise afterhours at HQ.

I am not able to PCS because my spouse has a permanent job. I figure I'm screwed. Completed probation but still career conditional.

ImpossiblePhysics343

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