In the confusing world of healthcare and insurance, it pays to pursue every possible option. Insurance rejections can be appealed, and the price that your pharmacy quotes is not necessarily the lowest price you can find.
Search for Discounts
For years, it was widely reported that semaglutide and tirzepatide cost about $1,000 per month. Cash prices may still be that high at the counter of your neighborhood pharmacy, but the drugmakers have recently made their products available for much lower prices through different avenues.
In some cases, these lower-cost medications may be administered with a vial and syringe, or in pill form, rather than via easy-to-use prefilled injector pens.
In addition, the drugmakers sometimes offer coupons and savings cards that can considerably lower the out-of-pocket cost for as long as one year. Not everyone qualifies for these programs, however, and they can’t be used indefinitely.
Appeal Lost Coverage
Bridget Roberts, 37, was reapproved for Zepbound by remaining persistent. It started when the Pottsgrove, Pennsylvania, resident received a letter that her insurance company was no longer covering the GLP-1.
“Initially, I felt I was doomed,” she says. “Something was finally working for me, and I was more alive than ever, and they wanted to take it from me.”
“It was like she was talking in code, like she knew something I didn’t,” Roberts says. She and her doctor were equally confused because she already had a prior authorization, but when the doctor put in the new request, her medication was approved.
Switch Diagnoses
Other GLP-1 users have successfully retained coverage by changing the diagnosis indicated on their prescriptions.
“Many GLP-1s are FDA approved for more than just weight loss, including type 2 diabetes, cardiovascular risk reduction, and even stroke prevention in certain populations,” says Supriya Rao, MD, an obesity physician and the director of medical weight loss at Lowell General Hospital in Lowell, Massachusetts. Some are also approved for a liver condition known as metabolic dysfunction-associated steatohepatitis (MASH).
If your insurer canceled coverage for a weight loss medication, it’s possible that it will cover the same medication for a different condition, such as sleep apnea, heart disease, or MASH. A new prescription for a new condition “can make the difference between full denial and full coverage,” says Dr. Rao.
Brianna Johnson-Rabbett, MD, an endocrinologist with Nebraska Medicine and a director of the American Board of Obesity Medicine, offers some examples. “If someone has established cardiovascular disease and obesity or overweight, Wegovy can be prescribed under that indication,” Dr. Johnson-Rabbett says. “If someone has moderate to severe obstructive sleep apnea and obesity, Zepbound can be prescribed for that indication.”
Switching diagnoses is no guarantee of coverage, however. “Insurance still may decide not to cover a medication, even if FDA indications for prescribing that medication are met,” says Johnson-Rabbett.