My insurance covers Ozempic for diabetes but denied the exact same drug for obesity. How is this okay?
I’m so frustrated right now and need to vent. I’ve been struggling with obesity for years (5’4, currently 287lbs) and my A1C is 5.9 – technically prediabetic but not quite diabetic yet. My doctor recommended Ozempic to help with weight loss and prevent me from becoming fully diabetic. Insurance denied it. The reason? I don’t have an actual diabetes diagnosis.
Here’s what makes me crazy – if I just waited until my A1C hit 6.5 and I became diabetic, THEN they’d cover the exact same medication. So basically they’re incentivizing me to get sicker before they’ll help? My doctor even wrote a letter explaining that preventing diabetes is better than treating it, but they still said no.
The out of pocket cost is like $900+ per month which I absolutely cannot afford. I’ve tried Wegovy (the weight loss version) and that was denied too. I’m stuck in this weird zone where I’m sick enough to need help but not sick enough for insurance to care.
Has anyone else dealt with this? Did you have any luck appealing? I’m considering just paying out of pocket for compound semaglutide but I don’t even know if that’s legit. This whole system feels so backwards.
Welcome to the absolute insanity of US healthcare. I went through the exact same thing last year. My BMI was 38, blood pressure creeping up, but A1C was 5.7. Denied. I appealed twice with letters from my doctor and an endocrinologist. Both denials. What finally worked for me was going through a compounding pharmacy – I pay about $250/month for semaglutide which isn’t cheap but way better than $900. My doctor recommended Empower Pharmacy and they’ve been legit so far, proper testing and everything. Just make sure wherever you go does third party testing. Some of these compound places are sketchy but there are good ones out there.
I feel your pain but honestly I had the opposite problem. I’m diabetic (A1C was 8.1 at diagnosis) and my insurance covered Ozempic right away but I had to fight them when my doctor wanted to increase my dose for better results. They kept saying the higher dose wasn’t “medically necessary” even though my numbers weren’t where they needed to be.
What MaxR said about compounding is worth looking into. Also have you asked your doctor about Mounjaro? I know some people have had better luck with insurance covering that one for weight loss since it has the dual approval. The prior authorization process is a nightmare no matter what though. Definitely appeal if you haven’t done that yet – sometimes they deny automatically and hope you just give up tbh