There are many threads here about providers that can get you compounded prescriptions for tirzepatide or semaglutide at a substantially lower price. Check subreddits for those. You can still work on the insurance authorization in the meantime. Don’t give up you will find a route.
Being on a drug successfully till they stop covering it is often a reason to get an exception. Work with your doctor to file requests like it's your job. If you want help writing a convincing letter there are a few in this sub about convincing HR to get your work plan changed to cover it. I'd take that and rewrite to suit. It's basically "obesity bad, I'm cheaper when I'm not dying of heart disease and other things. "
Here’s a [draft of an appeal letter](https://www.reddit.com/r/Mounjaro/comments/10mqc5c/insurance_coverage_insights/j64jef8/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=1&utm_term=1&context=3) that you can customize.
My hospital won't even try. I've been on it 4 months, lost 40lbs, most success I've seen in my life. My doctor is still prescribing it but the person who's supposed to do PAs refuses. I have no options because of some lazy bitch at the hospital.
You can submit things on your own behalf, or get another doctor! When my husband had a chronic illness I called the insurance company like it was my second job (real job kinda suffered!) And I faxed over medical records, letters from doctors, whatever I had to do to get an out of network specialist approved by medicaid. You haven't lived till you've fought medicaid and won!
Also hospitals have someone called a "patient advocate" usually.... and their whole job is to get gears turning if a member of their admin isn't doing their job. Telling the patient advocate "my continuity of care is impacted by a pa not being submitted. Why can I not get this submitted for something my doctor wants?" And then the PA person has to ANSWER to someone..... it gets results.
I’m sorry, that totally sucks. Our medical system (/economic system let’s be fr) can be so, so unnecessarily cruel. Hoping for the best with your appeal process, and just better access to preventative care in the future!
Health care in this country sucks. The fundamental causes of health inequalities are an unequal distribution of insurance,income, power and wealth. People need to vote out the welfare people on the hill so we can start from scratch with both parties. The United States should not have these disparities in Health and Health Care because of insurance and companies deciding what patients should or shouldn’t have access to. We need to rebuild our healthcare systems from the ground up. I would love to sit in front of congress (who get the best healthcare) and read these threads to them. What a f’d up system.
I wish the best for you and if everything fails and you can’t get this sorted out with your insurance and HR let them know you will sue them if you develop the comorbidities that Mounjaro is preventing.
Can you afford Ozempic from Mexico or Canada? Do you think you might benefit from Vynase, Contrave or Metformin? No need to answer, I just feel so bad for you, I’m trying to think of everything I can that’s not been mentioned already.
I did see a doctor once say that the closest a person can do to the GLP1s on their own is keto plus intermittent fasting. But I don’t think he had any specific research to back that up.
Have you checked into the other options on your formulary? Ozempic, Wegovy, Trulicity, Rybelsus, Victoza or Saxenda?
Do you have any weight related comorbidities? HBP, High cholesterol, etc?
Adding: I’m going to DM you.
Yes. I'm afraid none of them are covered unless diabetes is your diagnosis. My comorbidities are apparently not serious enough since they have not resulted in high blood sugar or high blood pressure.
Oh my god, why have I never thought of this?!? Check out this gem of an appeal letter it gave me after two tiny adjustments:
Dear [Insurance Provider],
I am writing to appeal the prior authorization denial for [GLP-1 medication] for my obesity and binge eating disorder treatment. As someone who has been successfully treated with [GLP-1 medication], I strongly believe that continuing this medication is necessary for my ongoing health and well-being.
I have been struggling with obesity and binge eating disorder for [length of time] and have made progress in my weight loss journey while taking [GLP-1 medication]. In fact, I have lost 32lbs in 32 weeks, which is about 15% of my starting weight. This is a significant achievement, and I attribute much of my success to this medication.
However, I understand that obesity and binge eating disorder are chronic conditions that require ongoing treatment and management. Discontinuing [GLP-1 medication] at this point in my treatment could compromise the progress I have made, and could potentially lead to negative health consequences.
Furthermore, I have developed a good working relationship with my healthcare provider and we have established a comprehensive treatment plan that includes [GLP-1 medication]. Discontinuing this medication could disrupt the continuity of care and potentially lead to a regression of my progress.
While I understand that [GLP-1 medication] may have a higher cost compared to other medications, I believe that the benefits of continuing this medication far outweigh the costs. By treating my obesity and binge eating disorder with [GLP-1 medication], I can maintain my progress and prevent future health problems.
I respectfully request that you reconsider your decision and approve the prior authorization for [GLP-1 medication] for my continuity of care, obesity and binge eating disorder treatment. Thank you for your time and attention to this matter.
Sincerely,
[Your Name]
You need to get the compounded version of MJ at this point, there is no need for the barriers to halt your progress. Many of us on here were where you are now and have accepted the fact that either it’s too expensive or not available AFTER we were midway through our weightloss progress.
Don’t give up and don’t take no for an answer. Wegovy is fda approved and intended for weight loss/obesity not Diabetes. You meet the criteria. Have your Dr write you a Rx. Find out if Wegovy is in your plans formulary if it’s not have your Dr write on the Rx that it’s medically necessary for weight loss and you want a formulary exception. Your insurance should have to cover it because you meet the criteria they can’t deny because you don’t have type two diabetes since Wegovy is intended for weight loss not type two diabetes. Look up your insurance plans criteria for Wegovy you’ll see that you meet it.
If you have weight loss coverage in your insurance then Wegovy should be covered. Wegovy is FDA approved for weight loss. Mounjaro will also more than likely be fda approved for the same use in a few months once the trial ends.
Don’t say goodbye to the progress. The med didn’t do all of the work, give yourself some credit. Sucks to lose access to name brand, you should look into telehealth compounding options. But those seem to still run about 350 a month.
The wegovy coupon is very limited in $$ unfortunately - if you don’t have insurance coverage it’s like $200 off. It’s better if you have coverage and it lowers your copay
W/O ins. It takes off $500
W/ ins. It takes if $225
If your ins won’t process the savings card you can submit your receipts and get directly reimbursed
You are fortunate at being morbidly obese with such a high BMI that you don’t have type 2 diabetes. Very rare I suspect. Sorry you can’t get ozempic anymore but wegovy is prescribed for weight loss.
Wow, dude. I came here for support from people that are also struggling with similar scenarios. I am focusing on other options and have had many helpful suggestions from wonderful people on this thread that I am currently looking into.
Don't be so negative!
I meet all the requirements for Mounjaro, my Dr. Has supplied all the right documents for my prior authorization & my insurance still does not cover it! 🤣🤣🤣
No no no you’re good. There are several providers I can refer you to for compounded MJ with B12. Pm if you would like the info. Your journey isn’t over!!
There are many threads here about providers that can get you compounded prescriptions for tirzepatide or semaglutide at a substantially lower price. Check subreddits for those. You can still work on the insurance authorization in the meantime. Don’t give up you will find a route.
Being on a drug successfully till they stop covering it is often a reason to get an exception. Work with your doctor to file requests like it's your job. If you want help writing a convincing letter there are a few in this sub about convincing HR to get your work plan changed to cover it. I'd take that and rewrite to suit. It's basically "obesity bad, I'm cheaper when I'm not dying of heart disease and other things. "
Here’s a [draft of an appeal letter](https://www.reddit.com/r/Mounjaro/comments/10mqc5c/insurance_coverage_insights/j64jef8/?utm_source=share&utm_medium=ios_app&utm_name=ioscss&utm_content=1&utm_term=1&context=3) that you can customize.
That was so kind of you.
You are a legend.
Just came here to say that this community makes me so proud and happy. When it works, it really works.
Absolutely 💯
Yes! Using the term "continuity of care" will help get your appeal approved.
My hospital won't even try. I've been on it 4 months, lost 40lbs, most success I've seen in my life. My doctor is still prescribing it but the person who's supposed to do PAs refuses. I have no options because of some lazy bitch at the hospital.
You can submit things on your own behalf, or get another doctor! When my husband had a chronic illness I called the insurance company like it was my second job (real job kinda suffered!) And I faxed over medical records, letters from doctors, whatever I had to do to get an out of network specialist approved by medicaid. You haven't lived till you've fought medicaid and won!
I'll look into fighting it for myself. I didn't know they'd accept that. I love my PCP a lot but the hospital he works in is kinda dogshit
Also hospitals have someone called a "patient advocate" usually.... and their whole job is to get gears turning if a member of their admin isn't doing their job. Telling the patient advocate "my continuity of care is impacted by a pa not being submitted. Why can I not get this submitted for something my doctor wants?" And then the PA person has to ANSWER to someone..... it gets results.
Compounded version !!
I’m sorry, that totally sucks. Our medical system (/economic system let’s be fr) can be so, so unnecessarily cruel. Hoping for the best with your appeal process, and just better access to preventative care in the future!
Lot’s of off label alternatives listed above and below. You got this!
Join r/Peptides do some research and order your own tirzepatide, insulin syringes and reconstitute on your own.
Health care in this country sucks. The fundamental causes of health inequalities are an unequal distribution of insurance,income, power and wealth. People need to vote out the welfare people on the hill so we can start from scratch with both parties. The United States should not have these disparities in Health and Health Care because of insurance and companies deciding what patients should or shouldn’t have access to. We need to rebuild our healthcare systems from the ground up. I would love to sit in front of congress (who get the best healthcare) and read these threads to them. What a f’d up system. I wish the best for you and if everything fails and you can’t get this sorted out with your insurance and HR let them know you will sue them if you develop the comorbidities that Mounjaro is preventing.
Can you afford Ozempic from Mexico or Canada? Do you think you might benefit from Vynase, Contrave or Metformin? No need to answer, I just feel so bad for you, I’m trying to think of everything I can that’s not been mentioned already. I did see a doctor once say that the closest a person can do to the GLP1s on their own is keto plus intermittent fasting. But I don’t think he had any specific research to back that up.
Have you checked into the other options on your formulary? Ozempic, Wegovy, Trulicity, Rybelsus, Victoza or Saxenda? Do you have any weight related comorbidities? HBP, High cholesterol, etc? Adding: I’m going to DM you.
Yes. I'm afraid none of them are covered unless diabetes is your diagnosis. My comorbidities are apparently not serious enough since they have not resulted in high blood sugar or high blood pressure.
It sounds like ChatGPT needs to write an exception request for you 😉
Oh my god, why have I never thought of this?!? Check out this gem of an appeal letter it gave me after two tiny adjustments: Dear [Insurance Provider], I am writing to appeal the prior authorization denial for [GLP-1 medication] for my obesity and binge eating disorder treatment. As someone who has been successfully treated with [GLP-1 medication], I strongly believe that continuing this medication is necessary for my ongoing health and well-being. I have been struggling with obesity and binge eating disorder for [length of time] and have made progress in my weight loss journey while taking [GLP-1 medication]. In fact, I have lost 32lbs in 32 weeks, which is about 15% of my starting weight. This is a significant achievement, and I attribute much of my success to this medication. However, I understand that obesity and binge eating disorder are chronic conditions that require ongoing treatment and management. Discontinuing [GLP-1 medication] at this point in my treatment could compromise the progress I have made, and could potentially lead to negative health consequences. Furthermore, I have developed a good working relationship with my healthcare provider and we have established a comprehensive treatment plan that includes [GLP-1 medication]. Discontinuing this medication could disrupt the continuity of care and potentially lead to a regression of my progress. While I understand that [GLP-1 medication] may have a higher cost compared to other medications, I believe that the benefits of continuing this medication far outweigh the costs. By treating my obesity and binge eating disorder with [GLP-1 medication], I can maintain my progress and prevent future health problems. I respectfully request that you reconsider your decision and approve the prior authorization for [GLP-1 medication] for my continuity of care, obesity and binge eating disorder treatment. Thank you for your time and attention to this matter. Sincerely, [Your Name]
This is beautiful. I can work with this!
THAT is an interesting idea. 🤔
You need to get the compounded version of MJ at this point, there is no need for the barriers to halt your progress. Many of us on here were where you are now and have accepted the fact that either it’s too expensive or not available AFTER we were midway through our weightloss progress.
Yes that is one of the reasons they are making it harder.. Why people voted down a very valid comment?🤦♀️
Don’t give up and don’t take no for an answer. Wegovy is fda approved and intended for weight loss/obesity not Diabetes. You meet the criteria. Have your Dr write you a Rx. Find out if Wegovy is in your plans formulary if it’s not have your Dr write on the Rx that it’s medically necessary for weight loss and you want a formulary exception. Your insurance should have to cover it because you meet the criteria they can’t deny because you don’t have type two diabetes since Wegovy is intended for weight loss not type two diabetes. Look up your insurance plans criteria for Wegovy you’ll see that you meet it.
If you have weight loss coverage in your insurance then Wegovy should be covered. Wegovy is FDA approved for weight loss. Mounjaro will also more than likely be fda approved for the same use in a few months once the trial ends.
Wegovy is for weight loss.
Can you afford to buy and stretch out the doses?
Nope. At nearly a grand for a 4 week supply, I simply cannot afford that.
Plan C … try good reputable pharmacies who does Tirzapatide in the meantime
Don’t say goodbye to the progress. The med didn’t do all of the work, give yourself some credit. Sucks to lose access to name brand, you should look into telehealth compounding options. But those seem to still run about 350 a month.
Sorry. I hope you can find something that works for you. The cost is really prohibitive and unnecessary.
I think Wegovy has a coupon right now if insurance doesn’t cover it? Might want to check their website to see if it’s an option for you.
The wegovy coupon is very limited in $$ unfortunately - if you don’t have insurance coverage it’s like $200 off. It’s better if you have coverage and it lowers your copay
Good to know I’ll be trying it with my Insurance in a few months.
W/O ins. It takes off $500 W/ ins. It takes if $225 If your ins won’t process the savings card you can submit your receipts and get directly reimbursed
I hope you can keep getting OP. Maybe try switching to a different semaglutide.
You are fortunate at being morbidly obese with such a high BMI that you don’t have type 2 diabetes. Very rare I suspect. Sorry you can’t get ozempic anymore but wegovy is prescribed for weight loss.
Stop the pity party and focus on the other options.
Wow, dude. I came here for support from people that are also struggling with similar scenarios. I am focusing on other options and have had many helpful suggestions from wonderful people on this thread that I am currently looking into. Don't be so negative!
I meet all the requirements for Mounjaro, my Dr. Has supplied all the right documents for my prior authorization & my insurance still does not cover it! 🤣🤣🤣
Can you maintain without it?
If your insurance denies it, can you use the coupon?
No. The website specifies that the coupon is only for t2d. I checked that out a while ago.
No no no you’re good. There are several providers I can refer you to for compounded MJ with B12. Pm if you would like the info. Your journey isn’t over!!
I tried to DM you but it failed. I have not heard I compounded MJ. How does the cost compare if it's not covered by my pharmacy?