Insurance denied my Wegovy refill after 6 months of coverage. Anyone else dealing with this?
So I’ve been on Wegovy since last March and my insurance (BCBS) has been covering it with a $25 copay. Lost about 38 lbs so far and honestly it’s been life changing. I went to refill my prescription this week and the pharmacy told me it was denied – like completely rejected. I called my insurance and they’re saying they need “new prior authorization” and that my doctor has to prove I’m still meeting medical necessity criteria?? I’ve literally been on it for 6 months without any issues.
I’m so frustrated because I’m finally making progress and now I’m looking at either paying $1400 out of pocket or going without until this gets sorted out. My doctor’s office said they submitted the PA but it could take 2-3 weeks. Has anyone else had their insurance suddenly pull coverage like this? Is this normal after a certain time period? I’m worried they’re just going to deny it completely. Really don’t know what to do here and I’m already feeling anxious about missing doses.
Ugh this happened to me with Aetna back in September. They required a new PA at the 6 month mark to prove I’d lost enough weight to justify continuing. My doc had to submit my weight records and basically write a letter saying I was responding to treatment. Took about 10 days to get approved again. Super annoying but they did end up approving it. In my case I think they wanted to see at least 5% weight loss from starting weight. Def call your doctor’s office and ask them to mark it as urgent – sometimes that speeds things up.
This is becoming really common unfortunately. A lot of insurers are doing “step therapy” checks every 6 months now because of how expensive these meds are and how many people are requesting them. What Mike said is right – they want documented proof you’re actually losing weight and that it’s medically necessary to continue. Some people have had luck asking their pharmacy about manufacturer coupons or savings programs while waiting for the PA to go through. I think Novo Nordisk has one but I’m not 100% sure what the requirements are. Worth asking about tho since 2-3 weeks without doses could definitely affect your progress.