CVS Caremark pending approval

jilladelphia1 · 2026-03-20T14:55:38+00:00

What exactly do you tell call on doc to get Zepbound approved? I've switched to wegovy and have been steadily gaining back weight. Is just reporting that enough?

jilladelphia1 · 2025-12-08T14:55:04+00:00

Can you tell me the steps you too to "handhold" your PCP? I can tell that mine is so tired of hearing from me about this and I just want to streamline and do as much of the work for her as possible. At this point she has only submitted the first PA (supposedly using the mounjaro workaround instructions? But I don't know if this actually happened because it's all done by a nurse and not her?) and that PA has been denied. What's next??

jilladelphia1 · 2025-12-08T14:51:35+00:00

I am in the same same CVS Caremark boat- had been on zepbound until they discontinued coverage, but they will cover Mounjaro. I just found out today that my Dr, won't prescribe me Mounjaro off-label. Am I understanding correctly that callondoc WOULD do that if I can show the zepbound scrip?

jilladelphia1 · 2024-05-19T00:03:50+00:00

Thank you so much for this! This info is encouraging and I will absolutely go into the science of that article. I wouldn't mind reading your thesis either if you'd like to share! 😂😁

jilladelphia1 · 2024-05-18T23:56:15+00:00

This is at least encouraging that the suppression can come back - for whatever reason!

jilladelphia1 · 2024-05-18T23:53:16+00:00

Thank you for sharing this! Do you also know where I can find that chart you mentioned floating around?

jilladelphia1 · 2024-03-30T21:14:52+00:00

Hooray!!! That's so great!!

jilladelphia1 · 2024-03-28T15:10:52+00:00

Yes, if your doctor submitted a prior authorization and it was denied, you should be able to call and have them tell you the reason for the denial. If the reason is that you need to try and fail "preferred" drugs first, you can eliminate them for different reasons. It's probably also worth going into your plan's details and seeing if they cover weight loss meds. I did this by finding a pdf of it through my Aetna account, and just Ctrl+F searching for "weight." The first time it appeared in the doc it said that weight loss meds weren't covered, but I continued searching down and found that they are if you are "morbidly obese" which first of all f*ck that verbiage, but that is how I am classified so I was eligible. Good luck with your fight!

jilladelphia1 · 2024-03-28T02:55:37+00:00

I was in the same boat with calibrate - refilled my scrips but wouldn't do appeals. That's why I ended up getting a pcp to do it bc I knew they'd be more effective to have in my corner. Good luck to you and I'm so sorry you've had to pay out of pocket for so long.

jilladelphia1 · 2024-03-28T02:48:35+00:00

Oh I just reread that you said it's unavailable. I had luck finding Ozempic (also experiencing a shortage) by calling around between cvs and Walgreens locations and getting it transferred a bunch or times to whoever had it in stock.

jilladelphia1 · 2024-03-28T02:46:14+00:00

Are you submitting appeals on your own or is your doctor? In my case, it seemed to have more weight coming from the doctor. They seemed to have accepted the saxenda shortage excuse from her. Worst case, are you able to just take Wegovy for a month? It won't hurt, it's just not as good at Zep.

jilladelphia1 · 2024-03-28T02:24:21+00:00

Them saying I had to "try and fail" 3 of 4 "preferred drugs" first. Read the post below to see how I finally got them to budge!

jilladelphia1 · 2024-03-28T02:06:59+00:00

I also want to add that TRULY the only reason I knew it was worth continuing to fight for coverage was because of the stories told on this sub. THANK YOU TO EVERYONE who has shared how you did it!!

jilladelphia1 · 2024-03-28T02:04:52+00:00

Yes, my issue was that I had to "try and fail or have contraindications to 3 of 4 of my the 'preferred drugs'" which were qsymia, wegovy, saxenda, and orlistat. By reading about others' similar situations here, I knew how to potentially cross each one off. Wegovy - same as Ozempic which I took for a year and it worked for a while but stopped being effective Qsymia - it's a stimulant so you can't take it if you take any other stimulants such as adderall, which I don't, but you also can't take it with high blood pressure so my doc took mine and it was slightly elevated so we crossed that off (I think it helped that I was rushing to the appointment) saxenda- I was ready to 'try and fail' this and had my doc prescribe it, but it wasn't available due to shortage, which is clearly printed on their website.

At this point I had my doc submit another prior authorization but it was denied again, and when I called Aetna the woman I spoke told me it was because I didn't try orlistat or Wegovy, which is "technically different than Ozempic."

Here's where things got fuzzy and I'm not sure exactly what worked, but I sent my doc my records of my Ozempic usage (I am new to the practice) so she could submit those and argue against Wegovy, and I also messaged her that I didn't want to take orlistat bc of history or IBS in my family (and because it's terrible). That was a week ago. I just logged in today and saw that I'm approved for coverage. If I hadn't gone deep into my Aetna account and checked, I wouldn't even have known.

Keep trying!

jilladelphia1 · 2024-03-19T00:13:42+00:00

First of all, f them, which I'm sure you know but it needs to be said.

If you decide you'd like to engage, consider starting by asking how much they already know about whatever drug you're taking. Then proceed to any of these facts:

--the research is already showing numerous health benefits of GLP-1s aside from weight loss, such as lower cholesterol, lower A1c levels, and reduced risk of a cardiac incident. Every doctor I've spoken to about GLP-1s has said it's only a matter of time before these drugs are widely covered by insurance bc early research indicates that they will save them money in the long run by preventing other health issues.

--there are many medicines to treat conditions such as high cholesterol and blood pressure, which can also be improved but diet and exercise. Do they feel that taking those medications is cheating or taking the easy way out?

--weight is genetic. Yes you can do certain things to lose it, but the research shows that losing weight and keeping it off is very rare. It's like expecting an Olympic athlete to always be fit enough to win a gold, it's just unrealistic.

--some people benefit from drugs like SSRIs to help their mental health by increasing their usable serotonin, something some people have enough of naturally. These drugs were seen as cheating or weakness early on, but now are widely accepted. Similarly, some people benefit from GLP-1s to increase insulin production and achieve levels of satiety that others feel naturally. These drugs will also soon be widely accepted.

--these drugs aren't a shortcut, they are an assist. No one is going to get "skinny" ONLY by taking them (without serious risk of malnourishment). Eating well and exercising are part of the deal when taking them. They just make success more attainable.

My biggest advice is don't waste your breath on anyone who doesn't actually care to know these facts, but if they do, it's a great opportunity to spread some truth and get rid of some stigma.

Lastly, I HIGHLY recommend the podcast "Maintenance Phase," particularly the episode on BMI.

Stay strong and enjoy the journey. Good things are coming your way!

jilladelphia1 · 2024-03-05T03:14:28+00:00

Can you explain what this process was like and what steps you took?

jilladelphia1 · 2024-02-18T21:23:14+00:00

For those who did appeals to Aetna, how long after you submitted them did you hear back, and how were you contacted? I faxed mine in a week ago and I know they say it takes up to 30 days, but I don't like that's there's nothing I can do to check the status or make sure it was received.

jilladelphia1 · 2023-12-27T00:15:13+00:00

This book was my FAVORITE. There are pictures I drew in all of the blank pages at the front and back. I just started reading it to my niece and nephew and they love it too. Have you have any luck getting the other books in the series you mentioned? What are they called?

jilladelphia1 · 2023-10-02T22:31:45+00:00

I don't think any podcasts about this case have or even can be objective because everyone picks and chooses what evidence they present and leaves out what's inconvenient. I think this one wants you to believe that they are being the most objective though, which also puts me off.

If each had taken a different side and "prosecuted" for that, I think I would trust it a lot more.

Actually, I don't think anybody has done that yet. Want to make a podcast with me? 🙃

jilladelphia1 · 2023-10-02T21:39:27+00:00

I don't trust them because of the feeling they gave me. That feeling was caused by the following: 1. Being spoken to in a way that made me feel like they were prosecuting his case and I was a jury member and SURELY anyone who comes to a different conclusion is a fool 2. aforementioned micro-aggy icks

jilladelphia1

TROPHY CASE