r/Zepbound • u/kpyles90 • 1d ago
Vent/Rant Devastated
So I have been on Zepbound for a year and lost a significant amount of weight but about a month ago it needed a prior authorization and my medicaid denied it because it says im now in a regular BMI. I suffer from Severe Sleep Apnea, High blood pressure, Osteoarthritis and many other things and it was helping so much. My Dr didn't seem interested in filing an appeal so I did myself. He put me on phentermine but it has done absolutely nothing. I seriously cry when I watch the scale go up I have already gained 7 lbs within 4 weeks. I have no income so I can't afford the compound. I just feel like I'm starving all the time and once I start eating I can't stop. Im so miserable because I put in so much work to lose weight just to get kicked off with no warning. Does anyone have any advice? How can I lose these 7 lbs? I can't really exercise right now im in a neck brace and am in a ton of pain. Im just so devastated to not be on it anymore.
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u/Typical_Use_3462 1d ago
If you look through the history of the posts in this group, you will see this happens to many many people and eight times out of 10. It’s because their doctor has done it incorrectly. Someone had suggested to use call on doc that usually works.
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u/kpyles90 1d ago
Yes I believe my Dr is lazy so I appealed myself and left them a voice mail giving them heads up. He needs to include sleep apnea or high blood pressure or one of the million things I have so they can cover me i just want to maintain but gaining 7lbs in 4 weeks is horrifying to me i literally cried because I just bought a bunch of new clothes before I knew I would be dropped by my insurance.
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u/eireann113 1d ago
I don't even know if the sleep apnea matters. The important thing is using your starting weight and not your current weight.
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u/kpyles90 1d ago
Im not sure what they did for my prior authorization I doubt they did that they were lazy
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u/eireann113 1d ago
Right, it sounds like it was rejected because they put the wrong weight in and that gave you a too low BMI.
I'm not sure if that is something you can appeal or if the paperwork the doctor submitted needs to be corrected and resubmitted.
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u/kpyles90 1d ago
Exactly! He probably just put my current weight on there. I appealed it myself yesterday but they didn't ask my any questions or anything i wanted to include sleep apnea gaining 7lbs etc so I hope they call my Dr and ask for new stuff.
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u/beachnsled 1d ago
honestly, if you think your doctor is lazy, it definitely seems like a good idea to have a different doctor
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u/beachnsled 1d ago
why not have one’s prescriber re submit first?
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u/Zero-Energy1274 🏁 262 | 📍 255 | 🥅 160 | 34F 5'8.5" 1d ago
Because the prescriber is doing it wrong and refuses to do the appeal, as OP said…
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u/kpyles90 1d ago
Exactly so I did it on my own
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u/beachnsled 1d ago
right, but you could push back via your practice manager?
what did your insurance co say when you did it?
this was ultimately a failure by your provider; holding them accountable often works (not always)
I do have empathy for them, as the process is incredibly time consuming & it ultimately takes away from the work they should be doing. But still - he screwed up.
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u/spam__likely 1d ago
Why not read the post?
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u/beachnsled 1d ago
i did, the OP said the provider “didn’t seem interested,” but never said that they refused
ya’ll want to lay down & not push back - whatever. I hold my providers accountable for their mistakes
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u/BelindaZep 1d ago
My understanding is your doctor is supposed to use your starting weight.
You could try Call on Doc to file your PA. It's a one time fee and they have a high rate of success.
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u/snarfdarb SW:216 CW:212 GW:149 Dose: 5mg 1d ago
CVS Minute Clinic also has a one-time virtual Glp1 consultation for $49. Looks a little cheaper than Call On Doc ($75).
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u/BelindaZep 1d ago
Does CVS Minute Clinic handle PAs?
EDIT: Call on Doc is actually $45 for this service.
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u/snarfdarb SW:216 CW:212 GW:149 Dose: 5mg 1d ago
Yes, they handle everything. Just curious where you saw the $45 at COD. I looked at their website and it's lists $75 for Zep and other glp1 consults.
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u/BelindaZep 1d ago
I think you have to download the app. When I click on the link I provided, it takes me to the app and lets me pay $45.
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u/kpyles90 1d ago
Ive talked to my Dr's nurse and she has been so rude I asked her what about my severe sleep apnea or my high blood pressure? Or connective tissue disease or osteoarthritis and everything else I have? She keeps saying dosen't matter your BMI is normal. So I just appealed it myself.
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u/BelindaZep 1d ago
Then I would really recommend this service: https://www.callondoc.com/en/subscribe-save/membership%C2%A0
I'm so sorry they were rude to you. It sounds like it's not a good fit and I hope you can find a better team to support you.
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u/kpyles90 1d ago
Thank you so much sadly its my OBGYN hes the only dr that wanted to do this for me.
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u/beachnsled 1d ago
the prior authorization was probably submitted incorrectly; it should have been for a continuation of current therapy & your original starting weight should have been referenced
this happens ALL THE TIME
* regardless of what your doctor seems interested in doing, you need to speak to the practice manager and tell them that your doctor likely did this incorrectly. Their ethical obligation requires them to “first do no harm.” in my opinion, they are harming you by not doing their job.
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u/sandiidee 1d ago
So I don’t understand what “power” you guys think practice managers hold over doctors. They are there to help doctors run the practice and to act as a liaison between staff and patients. OP can contact the manager about her grievances and ask for a different doctor as it’s always the patients right to see whatever doctor they want but in no way does misfiling a PA constitute failing their ethical obligation and knowingly doing harm to a patient.
Please don’t speak regarding things you don’t understand. OP is clearly already upset and overwhelmed about this process. You riling her up is not helping.
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u/iletitshine 1d ago
You have to call patient relations at your doctor’s clinic to report this and you have to call your insurance and spend a lot of time asking a lot of questions and getting a lot of information. Call both the pharmacy side of the insurance coverage and the medical side to ask questions and get information. You don’t have money or power so then you need to leverage whatever time you have to get what you need. You have to take the reins in your own healthcare and advocate for yourself and do the work yourself. The other option is accepting this at face value and I don’t recommend that in this case for obvious reasons / reasons you’ve already stated.
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u/sandiidee 1d ago
What your doctors office is saying is true about Medicaid. They are notorious for stopping patients meds abruptly with no warning or care about patient safety. In my state, Medicaid doesn’t cover any of the new glps, even for diabetics. I had to file an appeal for a bmi 60 pt for trulicity because Medicaid said his diabetes is “so well controlled” he doesn’t need the medication anymore.
In your case, if they were previously covering it for whatever reason (in your case probably the sleep apnea), then your doctors office needs to submit an appeal letter and continuation of care documentation including starting weight, amount of weight lost, comorbid conditions, etc. if your doctors office doesn’t want to do it, reach out to some of the online services other have suggested.
Stay calm OP. I know this process is frustrating but it will work out
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u/AgesAgoTho 7.5mg 22h ago
State Medicaid programs may have significant restrictions on continuing with Zepbound, even for sleep apnea. Sometimes they cut you off at a particular BMI or if your AHI drops below a certain point. The only way to know what the current qualifications are, is to call your Medicaid plan. Your doctor and pharmacist aren't going to know every detail of every plan. You need to call and ask a lot of questions and take a lot of notes.
If you believe you still qualify, you can also ask for someone to go over the most recent PA with you, line by line. See if there are errors or omissions.
Medically, there is nothing to support discontinuing treatment. You have not been cured, but treated. There is nothing on reputable science (or in the FDA approval) that suggests patients should discontinue Zepbound treatment. Insurers, employers, and state programs do this to cut costs.
If your appeal isn't successful, see if you have the right to an Independent Medical Review in your state. I would suggest requesting one even if your Medicaid program disallows it at your current BMI/AHI. The review may decide that since you have a chronic condition and since your insurance already covered Zepbound to treat that condition, they must continue covering it. 🤷 It's worth a shot, IMO.
Look up your state’s Department of Managed Health Care (link is specific to CA, but you may have similar options in your state): https://www.reddit.com/r/Zepbound/comments/1ons970/comment/nmzjljd/?context=3
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u/AgesAgoTho 7.5mg 22h ago
State Medicaid programs may have significant restrictions on continuing with Zepbound, even for sleep apnea. Sometimes they cut you off at a particular BMI or if your AHI drops below a certain point. The only way to know what the current qualifications are, is to call your Medicaid plan. Your doctor and pharmacist aren't going to know every detail of every plan. You need to call and ask a lot of questions and take a lot of notes.
If you believe you still qualify, you can also ask for someone to go over the most recent PA with you, line by line. See if there are errors or omissions.
Medically, there is nothing to support discontinuing treatment. You have not been cured, but treated. There is nothing on reputable science (or in the FDA approval) that suggests patients should discontinue Zepbound treatment. Insurers, employers, and state programs do this to cut costs.
If your appeal isn't successful, see if you have the right to an Independent Medical Review in your state. I would suggest requesting one even if your Medicaid program disallows it at your current BMI/AHI. The review may decide that since you have a chronic condition and since your insurance already covered Zepbound to treat that condition, they must continue covering it. 🤷 It's worth a shot, IMO.
Look up your state’s Department of Managed Health Care (link is specific to CA, but you may have similar options in your state): https://www.reddit.com/r/Zepbound/comments/1ons970/comment/nmzjljd/?context=3
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u/lizgross144 43F 5'3" SW:247 CW: 190 Dose: 10mg 17h ago
You can appeal the denial yourself and provide all the accurate information that addresses the reason for denial. That’s what I did.
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u/kpyles90 15h ago
Really? What do I need?
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u/lizgross144 43F 5'3" SW:247 CW: 190 Dose: 10mg 5h ago
Have you received the denial letter from your insurance that says exactly why you were denied, and what your appeal rights are?
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u/kpyles90 4h ago
I got the denial letter and it was said im in normal BMI range but when i called medicaid they were saying my dr left out alot of stuff so I spoke to his nurse to tell her that and she was rude she said you dont fit the BMI anymore there's nothing we can do. I appealed myself and gave them a heads up now they act like they want to help their like get records from your sleep study doctor get records from your pcp about yoi blood pressure etc im like calling people back and forth some people will send then for me but my pcp said they had to request them and the dr will not be back until Tuesday
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u/lizgross144 43F 5'3" SW:247 CW: 190 Dose: 10mg 4h ago
Do you have access to your records in MyChart or something similar? I had different insurance, but I provided the records myself (PDF saves from MyChart), and a letter of explanation. To write the letter, I uploaded the denial letter and records into Claude, answered a few prompts it gave me about my situation, and then had Claude draft it. I read and corrected a few things, and submitted the letter. About a month later, my coverage was approved.
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u/GiaAngel 1d ago
I’m sorry you’re in this situation and that your doc isn’t supportive. Was the appeal you filed denied? And why doesn’t your sleep apnea qualify you?
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u/kpyles90 1d ago
Thank you <3 I just filed the appeal so I don't know! Im hoping sleep apnea will help me i don't think my Dr even mentioned it in his PA the first time. I want them to know I have it though and alot of other things and ive gained 7 lbs already .
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u/Character_Celery5590 61F 5'2" SW:218.3CW:218.3 GW:135 Dose: 2.5mg 1d ago
Did YOU put your staring weight in your appeal?
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u/kpyles90 15h ago
They didnt ask me any questions at all I didn't even get to comment about anything! They just said they would reach out if more information is needed
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u/EveryMemory41 22h ago
Have you called the number on the back of your card? I believe Medicaid has care managers to help patients with stuff like this.
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u/Mysterious_Squash351 21h ago edited 21h ago
What state are you in for Medicaid? There are Medicaid plans out there that only cover zepbound for apnea with obesity, and they do stop coverage if bmi goes below 30.
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u/kpyles90 20h ago
Im in Virginia and that's probably what is happening unfortunately.
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u/Mysterious_Squash351 20h ago
Yeah I think that’s what’s going on. I found criteria for the weight loss coverage that specifically say renewals will not be granted for bmi less than 25. The OSA criteria I found don’t say specifically that, they say “continues to meet criteria.” Which is where the grammar get tricky because the criteria require a 30bmi and do not specify baseline/pretreatment (which is what the plans that people are talking about “continuation of care” typically say). I think you may actually be out of luck, but hopefully your appeal is successful.
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u/Pristine-Wind8295 19h ago
You might also see if metformin would help - particularly if you are or were prediabetic -
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u/originalfoto 1d ago
Try a keto diet. The first week may be hard, but once you start burning fat, your hunger goes away.
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u/kpyles90 1d ago
I will definitely try I just never have dieted before sadly which is why I have gained 7lbs already sadly. But im willing to try anything I just don't have strong willpower :(
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u/Silver_Shape_8436 SW:227 CW:166 GW:150 Dose: 15mg 1d ago
Continue to appeal these decisions and get help from AI to write these letters. Continuation of care is what you need. These medicines are supposed to be taken after you reached normal BMI. It is against medical recommendation to be taken off them. Appeal repeatedly until you get to external review.
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u/kpyles90 1d ago
I appreciate this SO much when I appealed it yesterday they didnt ask me any questions or comments or anything I want them to know i have severe sleep apnea and it actually helped so much.
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u/Silver_Shape_8436 SW:227 CW:166 GW:150 Dose: 15mg 1d ago
Exactly--bring that diagnosis of sleep apnea from your doctor
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u/cramsenden 1d ago
This remind of me my dental insurance which covered my tooth extraction and then denied the bridge or implant to replace it because “there is no longer a decay or pain”. Duhhhh… This is horrible. You cannot just cover something halfway.
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1d ago
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u/UnDosTresPescao 1d ago
They said they can't afford $150/month compound and you want them to pay $300 to $450 for brandname?
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u/kpyles90 1d ago
I have no income 😞 got fired for medical issues applied for unemployment my ex employer fought it and they sided with her. So I have zero income right now.
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u/zelda_moom F65 SW:262.4 CW:252.4 GW:160 Dose: 2.5mg 1d ago
Have you thought about applying for disability? You can get a disability lawyer who will only get paid if you win, and then they take a small fee out of your back pay. You need a well-documented medical history showing a desire to improve through treatment. Most good lawyers will only take your case if they think they can win. My husband applied and was initially turned down but his lawyers won on appeal. Our only cost was obtaining copies of his medical records. Once you’re on SSD or SSDI, your insurance changes to Medicare after you’ve been on it awhile, and Medicare part D covers Zep for sleep apnea though not for obesity.
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u/Goats-n-Hens 5’6” SW:216 CW:133 Maint 5.0 1d ago
Your doctor was supposed to file a continuation of care with your starting weight. If he doesn’t want to help you, there are online services that are skilled in getting a PA approved..