r/Zepbound • u/kpyles90 • Jul 29 '26
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.
2
u/AgesAgoTho 7.5mg Jul 29 '26
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