(Oona Zenda/KFF Health News)
Knowledgeable in-home caregiver misplaced her protection for Zepbound. She quickly realized getting it again was not simple.
“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 numerous the individuals who have been on ventilators or dying had one thing in widespread: 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 advised bariatric surgical procedure however couldn’t get Finley’s insurer to cowl it.
She exercised and watched what she ate, however she wasn’t shedding weight 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 advised Zepbound, a GLP-1 drug for weight problems.
Finley mentioned she nonetheless needed to put in numerous work to get wholesome. But the drug helped. Her sleep apnea improved dramatically. She misplaced weight.
Then her insurance coverage plan stopped masking Zepbound for weight reduction on the finish of final yr. That’s turn out to be widespread 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 folks have been on plans that dropped coverage for Zepbound and 12 million had plans that dropped Wegovy, one other GLP-1, in response to research by GoodRx, a web site that helps sufferers discover reductions on pharmaceuticals.
If you end up on this scenario, the following pointers may also help.
1. Read the wonderful print on protection.
While many plans don’t cowl GLP-1 medicine for weight reduction alone, they might make exceptions if in case you have different circumstances.
That was Finley’s scenario. She realized 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 lined for folks with Type 2 diabetes.
You can work together with your docs to display screen for qualifying circumstances, mentioned Caleb Alexander, a professor of epidemiology and medication on the Johns Hopkins Bloomberg School of Public Health.
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 displaying that the drug helped, she realized it might nonetheless be lined with a previous authorization — that’s when it’s important to get approval out of your medical health insurance earlier than it’ll cowl a medical cost.
Finley mentioned her doctor informed her a previous authorization was on file, however when she tried to refill her prescription, the pharmacist informed her Zepbound was denied.
2. File an attraction — and get some assist out of your physician.
Don’t surrender in case your remedy is denied, mentioned Catherine Varney, the weight problems medication director for UVA Health, the well being system affiliated with the University of Virginia in Charlottesville. Sometimes your insurer will relent on attraction, for those who make a very good case.
Finley made a number of irritating telephone calls and finally went digging via her on-line medical data.
“I had to do my own investigative work,” she mentioned.
Those data confirmed that Zepbound was certainly denied. Her physician had utilized for prior authorization, however it didn’t undergo, as a result of her insurer mentioned there was not enough information to again up the request. Somehow, her well being data, together with the sleep apnea testing outcomes, hadn’t made it to the best folks.
Finley finally obtained her fingers on the 17-page report and obtained slightly assist from ChatGPT to write down an attraction, displaying that the drug was mandatory for her primarily based on her prognosis and lined beneath her coverage.
This type of attraction will be numerous work. Luckily, many docs’ places of work will assist and understand how the system works, Alexander mentioned.
“I don’t think that patients should be expected to navigate these waters on their own,” he mentioned.
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3. Carefully doc your care.
Sometimes you’ll have to file a number of appeals if the primary one is unsuccessful, mentioned Tracy Zvenyach, the vice chairman for advocacy and analysis on the nonprofit Obesity Action Coalition, which receives monetary help from drugmakers together with Zepbound maker Eli Lilly and Wegovy producer Novo Nordisk.
Zvenyach additionally recommends retaining meticulous data. Some plans require one thing known as step remedy, which means sufferers must try to fail on different medicine or remedies earlier than getting lined for the one their physician needs 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 attraction 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 tense as a result of she hasn’t been capable of get new injections of Zepbound since mid-January.
4. Look for reductions for those who 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. (Try low cost websites like TrumpRx or GoodRx.)
Even with reductions, the medicine should not inexpensive for everybody. If you could have a health savings account or a versatile spending account, you should use it to pay for them with pretax {dollars}.
5. If you’re contemplating compounded GLP-1s on-line, look ahead to pink flags.
You might need seen advertisements for inexpensive 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 energetic ingredient because the brand-name medicine. But they aren’t authorised by the Food and Drug Administration.
Look out for quality and safety issues. Check the National Association of Boards of Pharmacy’s online pharmacy verification tool. Make certain the pharmacy getting ready your drug is licensed in your state. If it’s not, it is probably not present process inspections or complying with different legal guidelines.
After stretching out her remaining provide of Zepbound so long as she might, Finley is taking a compounded model of the drug whereas she continues the insurance coverage appeals course of.
6. Be persistent. And bear in mind to breathe.
Being informed no by an insurer is frustrating. But 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 Health’s Varney, who has consulted for Eli Lilly, mentioned not to surrender on making an attempt to get GLP-1s lined. “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 turn out to be inexpensive — low-cost even. Statins, that are used to deal with excessive ldl cholesterol, have been as soon as costly and onerous to get lined. Now, Alexander notes, they’re generic and infrequently value just some 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. Send us your tough 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 Health News.
