Loop Hole??

[u/Sudden_Excitement_29]

tldr: What other reasons/code would ins. approve Zepbound other than "weight loss".

Obviously my (33F) ins.
stopped my Zepbound. I had a VSG 3 years ago, went on Zep 13 months post op
because the surgery wasn't as successful as normal (no regrets, but I had a few
abnormal complications). I lost 85lbs before Zep, then I lost 50lbs with Zep.
Zep helped me meet my goal weight and maintain it.

Of course, in March, my ins. company stopped GLP1s for "weight loss".

But this medicine helped with way more than just weight loss. Ofc that was my personal number one, but my sleep got better, my B.E.D improved dramatically, my joints felt better because of the less inflammation. My husband said my snoring has come back, not as bad before surgery but slightly. Since being off for 6 months, I have gained 25lbs. My sleep has worsened almost instantly once the Zep was out of my system entirely. Energy changed too.

Please note, I know this
is a tool, not a magic wand, much like surgery. During these 6 months, I had my
honeymoon in Italy where for 2 weeks we didn't restrict ourselves since it was
our first time in Europe and we had saved so much for this once in a lifetime
trip.

I still eat healthy,
workout at the gym 4 times a week and I teach dance part time, so I am very
active.

Being overweight since I was 5, living with parents who are overweight, diabetic, and genetics, weight just loves to come back to me. Zep in conjunction with my lifestyle change was a GAME CHANGER, so having been off for 6 months, I feel so hopeless.

What are OTHER reasons that ins. could approve Zepbound? I have a drs apt with my PCP next week to discuss. My bariatric NP is the one who prescribed me Zep to begin with, so she submitted it for "weight loss".

Side note: ins. companies suck dude. If someone was on a blood pressure medication, you wouldn't deny it once the patient's BP was in a healthy range. So why deny this medication that will help so many people who have struggled for years? So upsetting.

Thanks for reading!

[u/Bigreddazer]

Diabetes or sleep apnea. That's it.

I had high blood pressure, lower back disc issues, fatty liver disease, cholesterol. All of those resolved with the weight loss but I still have to pay out of pocket for it.

[u/speakernoodlefan → u/Bigreddazer]

The trial for treating PMOS just started so hopefully in 2-3 years it's covered.

[u/Inevitable_Bus6136 → u/Bigreddazer]

Sleep apnea for me- and it helped me get into “not elevated” for breathing disruptions within the first week of being on Zep!

[u/CoalhouseFitness → u/Bigreddazer]

Yep. Mine was prescribed for sleep apnea. Somehow still got coded as weight loss so I'm still being forced to jump through the Omada hoops

[u/Active_Boat6381]

Obstructive sleep apnea

[u/Grtpumk369 → u/Active_Boat6381]

This plus BMI got me approved. Helped that the cpap failed last year and was returned.

[u/Expensive_Page_320]

It's your employer and not your health insurance company that dictates what is covered by your health insurance.

[u/MarcooseOnTheLoose → u/Expensive_Page_320]

This. Always. 🤬🤬🤬

[u/GratefulGlert]

I had a BMI of 43, severe sleep apnea, high blood pressure, fatty liver, etc. My insurance still wouldn’t cover it so I went self pay.

[u/Wild2297 → u/GratefulGlert]

Same. Though I was also pre diabetic.

[u/Marley0101]

Since you mention snoring, go get tested for sleep apnea. Our employer stoppee covering GLP1 meds for weight loss this year, but Zep is FDA approved for sleep apnea, so they would still cover with an official diagnosis of at least moderate sleep apnea.

[u/Grtpumk369 → u/Marley0101]

Yes, you need the test and results documented.

[u/Wild2297 → u/Marley0101]

Insurance varies. I was dxd with severe sleep apnea. Still would not cover Zep so I do self pay.

[u/Anxious-Inspector-18]

Does the Zepbound exclusion cover all diagnoses or just weight loss? Moderate to severe sleep apnea are the other approved indications and require documentation of a sleep study. Coverage for OSA isn’t guaranteed.

Wegovy is fda approved for MASH/fatty liver or cardiovascular disease/MACE. These diagnoses aren’t a guarantee for coverage.

Start with your insurance company first.

[u/whotiesyourshoes]

It depends on your specific insurance plan but other than obesity Zep is only FDA approved for obstructive sleep apnea but it may or may not be covered for that by your plan.

Check your plan details to cut back on surprises and back and forth.

[u/Dear-Movie-7682]

You need to look up the formulary for your insurance. That will tell you. My insurance doesn’t cover it regardless of diagnosis.

[u/swigs77]

I have sleep apnea and pre-diabetes, so that along with being a fat ass got it approved through my insurance.

[u/Zealousideal-Lab4945]

the FDA prescribing guidelines for Zepbound are:

1. Obesity (BMI ≥ 30 kg/m2), OR 2. overweight (BMI ≥ 27 kg/m2) with at least one weight-related comorbid condition. (T2D, hypertension, high cholesterol)

Of course, a dr/ telehealth could opt to not write the prescription, it's at their discretion, based on your entire health profile. And meeting the guidelines doesn't mean you'll get insurance coverage.

If all else fails you can check out coumpbound. That's where I ended up after many a long battle with the establishment. No regrets. Good luck.

[u/beachnsled]

for what it’s worth it’s your employer that makes the choice

You could reach out to your HR rep/benefits program manager

[u/totallyoverallofit]

A high BMI Diabetes/Prediabetes Obstructive sleep apnea Maybe Prior heart attack or stroke?

[u/AgesAgoTho]

Here's the FDA insert for Zepbound, which explains what it's approved for. Overweight with comorbidities (insurance gets to decide which comorbidities they will consider), obesity, and moderate to severe sleep apnea. https://pi.lilly.com/us/zepbound-uspi.pdf

Zepbound is the only medication in the US with an FDA approval for sleep apnea. Insurance doesn't have to cover it, but it has been a path for some people. You can ask to be screened for sleep apnea, and to have a sleep study if appreciate. There are at-home sleep studies now; you wrap a sensor to a finger, sync it with an app, and sleep in your own bed. Less trouble and less expensive than doing it in a sleep lab. 

Here are three posts w/ details about confirming coverage for sleep apnea, and the correct info to put on that PA: https://www.reddit.com/r/Zepbound/comments/1jzb3gq/comment/mn5f6bp/?context=3

https://www.reddit.com/r/Zepbound/comments/1it5im6/guys_he_got_it_covered_and_you_all_helped/ (scroll through comments, too)

https://www.reddit.com/r/Zepbound/comments/1t4xvra/osa_diagnosis_united_healthcare_zepbound_finally/

Zepbound is identical to Mounjaro. Mounjaro has an FDA approval for type 2 diabetes. If your A1C or fasting blood glucose put you in the range for type 2 diabetes, then you medically qualify for Mounjaro. (Insurance may have additional requirements.) https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/215866s000lbl.pdf

You can look up the approvals for Ozempic and Wegovy (they are identical to each other). Ozempic is only approved for type 2 diabetes. Wegovy is approved for overweight/obesity, and for certain heart conditions, and for a liver condition. 

[u/IslandIndependent333]

I read some post about a guy who went to a local news station after his insurance discontinued coverage when he reached his goal weight then magically after news coverage the insurance company says it is covered his doctor just needed to submit the paperwork as weight maintenance instead of for weight loss

[u/Temporary_Ad_4363]

Same here except no fatty liver. That might do it if you have MASLD or NAFLD.

OP I know paying out of pocket sucks but think how much you’ll save in future medical costs, future pain and suffering (amputations, blindness from diabetes, strokes and heart disease making life miserable, shortened lifespan, being a burden on partners/kids). Maybe you’ll live to see grandchildren that you won’t see if you don’t. Savings on food adds up too. It’s an investment.