Knowledgeable in-home caregiver misplaced her protection for Zepbound. She quickly realized getting it again was not easy.
“I was like: ‘What am I going to do? Hopefully I can just continue keeping this weight off.’”
— Deborah Finley, 50, of Lodi, California
Deborah Finley, 50, of Lodi, California, mentioned her weight began to fret her through the early days of covid. That’s when she seen a whole lot of the individuals who had been on ventilators or dying had one thing in frequent: weight problems.
“It was a scary time,” she mentioned. As a single mother, she was afraid “that I wouldn’t be here for my daughter.”
Finley had been recognized with sleep apnea and nonalcoholic fatty liver illness, and he or she was prediabetic. Her pulmonologist recommended bariatric surgical procedure however couldn’t get Finley’s insurer to cowl it.
She exercised and watched what she ate, however she wasn’t dropping pounds and her psychological well being suffered.
She remembers telling her physician: “Look, I’m at 223 pounds. I feel like I’m hitting this wall. I don’t know what else I can do.” That’s when he recommended Zepbound, a GLP-1 drug for weight problems.
Finley mentioned she nonetheless needed to put in a whole lot of work to get wholesome. However the drug helped. Her sleep apnea improved dramatically. She misplaced weight.
Then her insurance coverage plan stopped protecting Zepbound for weight reduction on the finish of final yr. That’s grow to be frequent as a result of GLP-1 medicine are costly for well being plans and the employers that pay for them.
“They started sending out notices to all the patients,” Finley mentioned. “And they said: ‘Look, we’re pulling this medication. We’re giving you 90 days’ notice to figure out what you want to do.”
From 2025 to 2026, 12 million individuals had been on plans that dropped protection for Zepbound and 12 million had plans that dropped Wegovy, one other GLP-1, in accordance with analysis by GoodRx, an internet site that helps sufferers discover reductions on pharmaceuticals.
If you end up on this scenario, the following pointers can assist.
1. Learn the nice print on protection.
Whereas many plans don’t cowl GLP-1 medicine for weight reduction alone, they might make exceptions in case you have different circumstances.
That was Finley’s scenario. She discovered that her insurer would cowl Zepbound if it was used to deal with obstructive sleep apnea, or MASH, a fatty liver illness. GLP-1s are additionally coated for individuals with Kind 2 diabetes.
You possibly can work together with your docs to display for qualifying circumstances, mentioned Caleb Alexander, a professor of epidemiology and drugs on the Johns Hopkins Bloomberg College of Public Well being.
Undiagnosed diabetes, he mentioned, is “the most likely scenario that would allow for someone to go from not being qualified to being qualified.”
Since Finley had sleep apnea and testing exhibiting that the drug helped, she discovered it may nonetheless be coated with a previous authorization — that’s when it’s a must to get approval out of your medical health insurance earlier than it can cowl a medical value.
Finley mentioned her doctor advised her a previous authorization was on file, however when she tried to refill her prescription, the pharmacist advised her Zepbound was denied.
2. File an enchantment — and get some assist out of your physician.
Don’t hand over in case your medicine is denied, mentioned Catherine Varney, the weight problems drugs director for UVA Well being, the well being system affiliated with the College of Virginia in Charlottesville. Typically your insurer will relent on enchantment, in case you make a great case.
Finley made a number of irritating telephone calls and finally went digging by means of her on-line medical information.
“I had to do my own investigative work,” she mentioned.
These information confirmed that Zepbound was certainly denied. Her physician had utilized for prior authorization, but it surely didn’t undergo, as a result of her insurer mentioned there was not enough information to again up the request. One way or the other, her well being data, together with the sleep apnea testing outcomes, hadn’t made it to the correct individuals.
Finley finally acquired her palms on the 17-page report and acquired slightly assist from ChatGPT to put in writing an enchantment, exhibiting that the drug was obligatory for her primarily based on her analysis and coated below her coverage.
This type of enchantment could be a whole lot of work. Fortunately, many docs’ workplaces will assist and know the way the system works, Alexander mentioned.
“I don’t think that patients should be expected to navigate these waters on their own,” he mentioned.
3. Rigorously doc your care.
Typically you could have to file a number of appeals if the primary one is unsuccessful, mentioned Tracy Zvenyach, the vp for advocacy and analysis on the nonprofit Weight problems Motion Coalition, which receives monetary help from drugmakers together with Zepbound maker Eli Lilly and Wegovy producer Novo Nordisk.
Zvenyach additionally recommends preserving meticulous information. Some plans require one thing known as step remedy, that means sufferers need to attempt to fail on different medicine or remedies earlier than getting coated for the one their physician desires them to take.
“Keep a history of other meds you’ve taken so you can provide documentation for step therapy requirements,” she mentioned. “Document dates of participation in any nutrition and physical activity program or membership.”
Finley filed an enchantment on Feb. 4, and though she anticipated a listening to inside 90 days, it hadn’t been scheduled but as of mid-June.
She mentioned it’s been anxious as a result of she hasn’t been capable of get new injections of Zepbound since mid-January.
4. Search for reductions in case you pay out-of-pocket.
The drugmakers that make Zepbound and Wegovy promote the medicines at a reduction to individuals who pay out-of-pocket as a substitute of utilizing insurance coverage. (Attempt low cost websites like TrumpRx or GoodRx.)
Even with reductions, the medicine will not be reasonably priced for everybody. If in case you have a well being financial savings account or a versatile spending account, you should use it to pay for them with pretax {dollars}.
5. For those who’re contemplating compounded GLP-1s on-line, look ahead to pink flags.
You might need seen adverts for reasonably priced off-brand weight problems medicine prescribed by on-line suppliers. These are compounded merchandise — that’s, made by specialised pharmacists as a substitute of a drug firm.
Compounded medicines are ready utilizing the identical lively ingredient because the brand-name medicine. However they aren’t permitted by the Meals and Drug Administration.
Look out for high quality and security difficultys. Verify the Nationwide Affiliation of Boards of Pharmacy’s on-line pharmacy verification device. Be sure the pharmacy making ready your drug is licensed in your state. If it’s not, it will not be present process inspections or complying with different legal guidelines.
After stretching out her remaining provide of Zepbound so long as she may, Finley is taking a compounded model of the drug whereas she continues the insurance coverage appeals course of.
6. Be persistent. And keep in mind to breathe.
Being advised no by an insurer is frustrating. However Alexander mentioned you usually produce other choices.
“If any appeal that we make is unsuccessful, there are other treatments that we can use,” he mentioned — for instance medicine like Contrave, or a less expensive mixture of generic naltrexone and bupropion.
UVA Well being’s Varney, who has consulted for Eli Lilly, mentioned not to surrender on making an attempt to get GLP-1s coated. “Take a breath, but go right back to it,” she mentioned, including that GLP-1s are superior to the older medicine in the marketplace.
Alexander mentioned he thinks weight problems medicine will finally grow to be reasonably priced — low cost even. Statins, that are used to deal with excessive ldl cholesterol, had been as soon as costly and onerous to get coated. Now, Alexander notes, they’re generic and infrequently value only a few bucks.
“I know it’s hard to imagine,” he mentioned. “But there will come a day when we no longer see these access barriers for GLP-1s.”
Healthcare Helpline helps you navigate the well being system hurdles between you and excellent care. Ship us your difficult query and we might faucet a coverage sleuth to puzzle it out. Share your story. The crowdsourced undertaking is a joint manufacturing of NPR and KFF Well being Information.
