Episode 162: How to Get Wegovy Covered

[00:00:00] [SPEAKER_00]: Welcome back to the Back on Track, Achieving Healthy Weight Loss, where I help you get

[00:00:05] [SPEAKER_00]: on track and stay on track with your weight loss journey.

[00:00:09] [SPEAKER_00]: I'm your host, Dr. Alicia Shelly.

[00:00:11] [SPEAKER_00]: So let's get started.

[00:00:28] [SPEAKER_00]: Are you frustrated trying to get your Wegovy or ZetBound covered?

[00:00:32] [SPEAKER_00]: And do you feel that insurance is stopping you from getting your weight loss medication?

[00:00:37] [SPEAKER_00]: Well, today's episode is for you.

[00:00:41] [SPEAKER_00]: We are talking about how you can navigate the insurances to get your weight loss medication

[00:00:47] [SPEAKER_00]: covered.

[00:00:48] [SPEAKER_00]: This is a huge problem for a lot of my patients.

[00:00:51] [SPEAKER_00]: In fact, it is the rate limiting step, meaning that if we can't overcome this insurance,

[00:00:57] [SPEAKER_00]: then the patient is left with paying hundreds and thousands of dollars for this medication.

[00:01:02] [SPEAKER_00]: And sometimes people can't pay that.

[00:01:04] [SPEAKER_00]: It's not in the budget.

[00:01:05] [SPEAKER_00]: And so today I wanted to maybe share with you just a couple of strategies on how you

[00:01:11] [SPEAKER_00]: can overcome this hurdle.

[00:01:14] [SPEAKER_00]: But first, before we get started, let's kind of talk a little bit about what these

[00:01:18] [SPEAKER_00]: medications are.

[00:01:19] [SPEAKER_00]: So we have for that FDA approved for weight loss, we have Wegovy, which is

[00:01:25] [SPEAKER_00]: a once weekly injection that helps with not only curbing your appetite, it also

[00:01:30] [SPEAKER_00]: regulates how many calories you're getting into.

[00:01:32] [SPEAKER_00]: I have some patients who say that it actually kind of takes away the food noise for

[00:01:37] [SPEAKER_00]: them, so they're not thinking about it.

[00:01:38] [SPEAKER_00]: And then we also have ZetBound.

[00:01:40] [SPEAKER_00]: The difference between ZetBound and Wegovy is that ZetBound kind of targets two

[00:01:44] [SPEAKER_00]: hormones that help with regulating appetite and reducing how much you eat, whereas

[00:01:49] [SPEAKER_00]: Wegovy targets one.

[00:01:50] [SPEAKER_00]: That's the difference.

[00:01:50] [SPEAKER_00]: But they're both once weekly injections.

[00:01:53] [SPEAKER_00]: They're also fairly new.

[00:01:54] [SPEAKER_00]: Wegovy came out in 2022.

[00:01:57] [SPEAKER_00]: ZetBound came out in 2023.

[00:01:58] [SPEAKER_00]: So they are fairly new and which makes it a little bit more difficult for them to be

[00:02:05] [SPEAKER_00]: able to, you know, for insurance to cover.

[00:02:08] [SPEAKER_00]: In history, normally insurances do take some time for them to cover certain

[00:02:14] [SPEAKER_00]: medications.

[00:02:15] [SPEAKER_00]: Although I will say that for both, it is covered by a lot of insurances.

[00:02:19] [SPEAKER_00]: But we do want to talk about where the backlog is and what I'm seeing.

[00:02:23] [SPEAKER_00]: So the reason why these medications are helpful, both of them, is that when we look at

[00:02:29] [SPEAKER_00]: the amount of weight loss that people are getting in the past, it was normal for

[00:02:33] [SPEAKER_00]: people to lose like 5 to 10 percent and we were happy.

[00:02:36] [SPEAKER_00]: But with these medications now you're getting closer to 15 to 20 percent.

[00:02:40] [SPEAKER_00]: And so it really makes a big difference.

[00:02:42] [SPEAKER_00]: And somebody who's trying to lose weight also Wegovy has been approved, FDA

[00:02:47] [SPEAKER_00]: approved to help individuals who have a preexisting condition of heart disease or

[00:02:53] [SPEAKER_00]: heart failure, heart attack, congestive heart failure and stroke.

[00:02:59] [SPEAKER_00]: It has been shown to reduce your risk of dying from a non-fatal stroke or non-fatal

[00:03:04] [SPEAKER_00]: MRI by 20 percent, which is very significant.

[00:03:08] [SPEAKER_00]: It's the reason why we ask people who have these conditions to be on a statin

[00:03:11] [SPEAKER_00]: because a statin cholesterol medication because this medication has been shown to reduce

[00:03:15] [SPEAKER_00]: your risk of mortality by 20 percent as well.

[00:03:18] [SPEAKER_00]: So with that being said, these are very important.

[00:03:21] [SPEAKER_00]: These medications can help people with not only losing weight, but changing their life

[00:03:26] [SPEAKER_00]: trajectory and their health most importantly.

[00:03:29] [SPEAKER_00]: But the question is how do we get it covered?

[00:03:31] [SPEAKER_00]: Because that's the bane of my existence.

[00:03:34] [SPEAKER_00]: So let's just talk about the different people who are candidates.

[00:03:38] [SPEAKER_00]: Now, a lot of times I do ask my patient to call.

[00:03:41] [SPEAKER_00]: So it's important that you do some groundwork first.

[00:03:44] [SPEAKER_00]: So you do need to either call your insurance or sometimes they have a website

[00:03:47] [SPEAKER_00]: where you can go and just kind of put the medication,

[00:03:50] [SPEAKER_00]: what Gobi's at bound in their search to see how much it will cover.

[00:03:54] [SPEAKER_00]: And when you call the insurance customer service, and I will say that customer

[00:03:59] [SPEAKER_00]: service people are very nice, but they're not really clinical.

[00:04:02] [SPEAKER_00]: I used to work in customer service and a lot of times you have a script

[00:04:05] [SPEAKER_00]: that you go through to help the patient, but you may not necessarily have all the

[00:04:09] [SPEAKER_00]: knowledge of what the medications do.

[00:04:10] [SPEAKER_00]: You just have a list of what's covered and what's not.

[00:04:12] [SPEAKER_00]: And so sometimes what my patients will do is that they'll call and the insurance

[00:04:17] [SPEAKER_00]: will say, oh, well we don't cover with Gobi or ZipBound, but we cover

[00:04:22] [SPEAKER_00]: Ozempic and Manjaro with a prior authorization.

[00:04:25] [SPEAKER_00]: Now I do want to say there is a difference between Ozempic and Manjaro

[00:04:30] [SPEAKER_00]: and Gobi and ZipBound.

[00:04:32] [SPEAKER_00]: The difference is this Ozempic and Manjaro are FDA approved for type 2 diabetes.

[00:04:38] [SPEAKER_00]: So that means you have to have type 2 diabetes.

[00:04:41] [SPEAKER_00]: And some insurances are really strict.

[00:04:44] [SPEAKER_00]: Not only do you have to have type 2 diabetes, they may say, hey, you have

[00:04:48] [SPEAKER_00]: to have tried Metformin or hey, you need to have an A1C that's greater,

[00:04:53] [SPEAKER_00]: a hemoglobin A1C which is a three month test that tells you the average

[00:04:57] [SPEAKER_00]: of your blood sugars.

[00:04:58] [SPEAKER_00]: But that test has to be over a certain level, definitely over 6.5,

[00:05:02] [SPEAKER_00]: but I've had one insurance say they have to be over 8.5 before

[00:05:05] [SPEAKER_00]: they were even covered.

[00:05:07] [SPEAKER_00]: So these are extremely important because first of all, the customer

[00:05:11] [SPEAKER_00]: services doesn't tell you that.

[00:05:13] [SPEAKER_00]: And so when you go back to your doctor and say, well, hey,

[00:05:16] [SPEAKER_00]: Gobi and ZipBound is not covered but Ozempic and Manjaro is and just

[00:05:20] [SPEAKER_00]: needs a prior authorization.

[00:05:22] [SPEAKER_00]: When the physician does the prior authorization, what happens is

[00:05:25] [SPEAKER_00]: that they have to answer these questions.

[00:05:27] [SPEAKER_00]: And the question is, does the person have type 2 diabetes?

[00:05:30] [SPEAKER_00]: If the answer is no, you instantly get denied.

[00:05:33] [SPEAKER_00]: Or if they said, does the patient have type 2 diabetes?

[00:05:35] [SPEAKER_00]: The answer is yes.

[00:05:36] [SPEAKER_00]: And has the patient tried metformin?

[00:05:38] [SPEAKER_00]: And the answer is no, then you may get denied.

[00:05:40] [SPEAKER_00]: Or if we have to send in your blood work and it doesn't show

[00:05:44] [SPEAKER_00]: an A1C at a certain amount, then you can't get denied too.

[00:05:48] [SPEAKER_00]: So it can be very frustrating for patients because you have

[00:05:51] [SPEAKER_00]: this false hope.

[00:05:52] [SPEAKER_00]: You're like, oh, well, these two aren't covered but this is,

[00:05:55] [SPEAKER_00]: and maybe this prior authorization that my doctor has to fill out

[00:05:58] [SPEAKER_00]: will just open the door.

[00:05:59] [SPEAKER_00]: But in actuality, that prior authorization is a way how the

[00:06:03] [SPEAKER_00]: closes the door because you have to meet their certain criteria.

[00:06:07] [SPEAKER_00]: And this particular criteria is not on that customer services.

[00:06:11] [SPEAKER_00]: They don't have access to that criteria so they can't tell you

[00:06:15] [SPEAKER_00]: what to expect, which once again, it's more time and frustration

[00:06:19] [SPEAKER_00]: on the patient.

[00:06:21] [SPEAKER_00]: So the first thing I would say to the insurance, so the first

[00:06:24] [SPEAKER_00]: thing I would do is number one, if you're interested in

[00:06:26] [SPEAKER_00]: starting any of these medications, call your insurance first.

[00:06:29] [SPEAKER_00]: Call them, talk to them.

[00:06:31] [SPEAKER_00]: If they say what Gobi and ZipBound are excluded, then what that signals

[00:06:36] [SPEAKER_00]: is that your insurance does not cover weight loss medications, period.

[00:06:40] [SPEAKER_00]: And the reason why your insurance does not cover weight loss

[00:06:42] [SPEAKER_00]: medication, period, is because your employer has to opt in

[00:06:48] [SPEAKER_00]: to covering weight loss medications.

[00:06:50] [SPEAKER_00]: So when your employer actually signs up for benefits for its employees,

[00:06:55] [SPEAKER_00]: it has to stay or check yes or no whether it includes

[00:06:58] [SPEAKER_00]: weight loss medications.

[00:07:00] [SPEAKER_00]: And due to it being an additional cost, some employers don't cover it.

[00:07:05] [SPEAKER_00]: It doesn't even matter the insurance.

[00:07:07] [SPEAKER_00]: It's more of the employer who where the issue is.

[00:07:11] [SPEAKER_00]: And in that case, you do want to talk to your human resources

[00:07:15] [SPEAKER_00]: to lobby them, to get your fellow employees to say, hey, we want

[00:07:21] [SPEAKER_00]: these medications covered as part of our benefits package.

[00:07:25] [SPEAKER_00]: This is important to us because your insurance will only do what

[00:07:29] [SPEAKER_00]: the employee or their client wants.

[00:07:32] [SPEAKER_00]: And so if you're finding that your employer is not covering it,

[00:07:36] [SPEAKER_00]: then you need to lobby your employer.

[00:07:39] [SPEAKER_00]: Now granted, not all of us work with a union, but if you work

[00:07:43] [SPEAKER_00]: with a union, then you need to bring that up so that they can

[00:07:45] [SPEAKER_00]: negotiate that when it's time to negotiate the contract with the union.

[00:07:49] [SPEAKER_00]: Also, hey, you never know by you getting more, because there may be

[00:07:53] [SPEAKER_00]: other people who would love to be on medications for weight,

[00:07:57] [SPEAKER_00]: but the employer is not opt in.

[00:07:59] [SPEAKER_00]: So they may be willing to sign a petition or going themselves and saying,

[00:08:03] [SPEAKER_00]: hey, can you all include this for next year?

[00:08:06] [SPEAKER_00]: Open enrollment is coming up in these next couple of months for many companies.

[00:08:10] [SPEAKER_00]: And so it's important that you lobby them and see if they may be willing to do it.

[00:08:16] [SPEAKER_00]: I know in our institution, we're so blessed that they have been able to cover it,

[00:08:20] [SPEAKER_00]: but that's taken a lot of people lobbying and asking and pestering.

[00:08:24] [SPEAKER_00]: You know what they say, the squeaky wheel gets the oil.

[00:08:27] [SPEAKER_00]: And so in order to see a change, sometimes you have to be that change maker and lobby them.

[00:08:31] [SPEAKER_00]: Also for those individuals who are on Medicare or Medicaid,

[00:08:36] [SPEAKER_00]: you may have to lobby your congressperson, the people who you vote for,

[00:08:40] [SPEAKER_00]: because in order to see if they can get covered, there is an act

[00:08:44] [SPEAKER_00]: on the floor of Congress called the TROA Act, T-R-O-A.

[00:08:49] [SPEAKER_00]: It's called Treat and Reduce Obesity Act.

[00:08:52] [SPEAKER_00]: It's been brought up multiple, multiple congresses, but it's in Congress currently.

[00:08:56] [SPEAKER_00]: And if you look, you can actually just google troa.com or Treat and Reduce Obesity Act,

[00:09:02] [SPEAKER_00]: or even go to the website, Obesity Action Coalition.

[00:09:06] [SPEAKER_00]: And you can actually search for who your congresspeople are,

[00:09:10] [SPEAKER_00]: and they give you a script or a letter that you can email to them or script if you call

[00:09:15] [SPEAKER_00]: them so they can support this act and this bill so that hopefully millions of people who

[00:09:21] [SPEAKER_00]: are on Medicare, not just people who are over the age of 65, but people who are on disability,

[00:09:27] [SPEAKER_00]: they'll be able to get access to these medications.

[00:09:29] [SPEAKER_00]: Because like I said before, these medications are not just to look better.

[00:09:33] [SPEAKER_00]: These medications are improving people's medical health, medical complications.

[00:09:38] [SPEAKER_00]: I had a patient tell me, she said, why is it that my insurance wants me to

[00:09:43] [SPEAKER_00]: get diabetes first before they cover medication that can help treat my weight,

[00:09:47] [SPEAKER_00]: which will reduce my risk of diabetes?

[00:09:49] [SPEAKER_00]: It makes no sense to me either.

[00:09:52] [SPEAKER_00]: But the only thing I can think of is that money, but still it doesn't make sense.

[00:09:56] [SPEAKER_00]: And so if we can right this wrong, if we can kind of help people with controlling

[00:10:01] [SPEAKER_00]: their weight, which will improve their heart outcomes, their high blood pressure,

[00:10:06] [SPEAKER_00]: their diabetes, actually by reducing your weight, it can reduce your risk of cancer.

[00:10:11] [SPEAKER_00]: Having obesity increases your risk of a cancer by 40% in the breast

[00:10:16] [SPEAKER_00]: and your estrogen related cancers like breast, ovarian, and uterine cancers.

[00:10:21] [SPEAKER_00]: So it makes a difference with what you can do by controlling one's weight.

[00:10:27] [SPEAKER_00]: So I'm sorry I get off on my soapbox, but I'm just saying we have work to do.

[00:10:32] [SPEAKER_00]: And we can be able to try to make that difference and not just change for yourself,

[00:10:37] [SPEAKER_00]: but a change for your fellow employees by either number one, petitioning your human

[00:10:42] [SPEAKER_00]: resources if they don't cover or they exclude weight loss medication in their plan.

[00:10:46] [SPEAKER_00]: If you're on Medicare, Medicaid, actually going to your congresspeople or your

[00:10:51] [SPEAKER_00]: representatives and saying, state representatives and saying that, hey, this needs to be covered.

[00:10:57] [SPEAKER_00]: And know there's resources that to give you the words to say,

[00:11:00] [SPEAKER_00]: to give you the script to say if you were to call them or the words to write,

[00:11:03] [SPEAKER_00]: if you were to email them and that go to Obesity Action Coalition,

[00:11:08] [SPEAKER_00]: they'll be able to lead you along that way.

[00:11:11] [SPEAKER_00]: So with that being said, the next step is, okay, so let's say the doctor has submitted

[00:11:19] [SPEAKER_00]: the medication to the pharmacy. What happens is if it does require prior authorization,

[00:11:24] [SPEAKER_00]: the pharmacy will send a request for prior authorization to the doctor.

[00:11:28] [SPEAKER_00]: Now it depends on the pharmacy. Normally they do it through a system called Cover My Meds

[00:11:34] [SPEAKER_00]: or a different system called Sure Scripts where the doctors can go in or the doctor's office

[00:11:39] [SPEAKER_00]: can go in and submit the information. That's the easiest because it's electronic

[00:11:43] [SPEAKER_00]: and it's easier to kind of upload documents to that if you need to like send them your

[00:11:48] [SPEAKER_00]: hemoglobin A1C or whatever else is needed to try to get it approved.

[00:11:52] [SPEAKER_00]: And so once that's done, then the insurance will either come back with approved or denied.

[00:11:59] [SPEAKER_00]: Now it may be conditional where it may be, hey, we need more documentations.

[00:12:04] [SPEAKER_00]: We need your progress notes. So it is important that when you go see your doctor

[00:12:08] [SPEAKER_00]: to get this prescription that they're kind of writing down all your complications,

[00:12:13] [SPEAKER_00]: the prior weight loss programs that you've tried, kind of in their progress note.

[00:12:18] [SPEAKER_00]: Because if they do ask for it, then you can send that into the insurance and they

[00:12:21] [SPEAKER_00]: can read it and say, okay, this patient has tried these different many medications

[00:12:25] [SPEAKER_00]: in the past for weight, it hasn't worked. She has been on a exercise,

[00:12:30] [SPEAKER_00]: physician assistant weight loss program and it hasn't worked.

[00:12:33] [SPEAKER_00]: And so maybe this can kind of help put you into the field of saying,

[00:12:37] [SPEAKER_00]: okay, let's approve it. But it's just important to have it because you just never know.

[00:12:41] [SPEAKER_00]: The other thing I would say is also too, once the doctor's office does the prior

[00:12:46] [SPEAKER_00]: authorization, it says either approved, then you're fine. You get the medication.

[00:12:49] [SPEAKER_00]: If it says you're denied, then the next thing that happens is that they actually

[00:12:53] [SPEAKER_00]: will give you an option to appeal the denial.

[00:12:57] [SPEAKER_00]: And so everyone is different, but usually you have like 30 to 90 days to appeal.

[00:13:02] [SPEAKER_00]: And so usually you can appeal by writing a letter. Now, the one thing I would say,

[00:13:07] [SPEAKER_00]: you kind of want to get all the verbiage in, there are different templates online.

[00:13:11] [SPEAKER_00]: So you can just say appeal letter for Wigovie template and you'll see some

[00:13:16] [SPEAKER_00]: templates that pop up that you can kind of use to kind of put your information

[00:13:20] [SPEAKER_00]: and your passion on why it's there. Also sometimes I like to, when I do my

[00:13:23] [SPEAKER_00]: appeal letters, I like to put the studies like, hey, this study says this will be

[00:13:27] [SPEAKER_00]: helpful and this is why this person should be on this medication.

[00:13:31] [SPEAKER_00]: I have to admit the approval weight is a little bit lower. It's like, I think

[00:13:35] [SPEAKER_00]: around 33, 34% on whether they appeal. They approve an appeal letter, but you never know

[00:13:41] [SPEAKER_00]: where you'll be in that percentage. And so it's better to do it and to get denied

[00:13:46] [SPEAKER_00]: than to not do it. And you could have gotten approved.

[00:13:49] [SPEAKER_00]: So make sure you're kind of writing that appeal letter.

[00:13:51] [SPEAKER_00]: Also, it's okay to if you want your doctor to do an appeal letter,

[00:13:55] [SPEAKER_00]: if you can say, hey, here's a template that you can utilize for the appeal letter.

[00:14:00] [SPEAKER_00]: They actually will be very happy because you know what? The doctors are very busy.

[00:14:03] [SPEAKER_00]: There's always something going on. And so to have something where they can kind of

[00:14:07] [SPEAKER_00]: craft it in their own language may be helpful. Just depending on your doctor,

[00:14:11] [SPEAKER_00]: some doctors are very open to it because it just kind of helps them to not have to

[00:14:15] [SPEAKER_00]: think of a new letter. They can just be able to utilize that template

[00:14:18] [SPEAKER_00]: and be able to get all the information across that you may need.

[00:14:22] [SPEAKER_00]: And then secondly, once you have that, you just kind of wait and see,

[00:14:26] [SPEAKER_00]: and we'll see if they approve it or not. So I know this is a lot of the process,

[00:14:31] [SPEAKER_00]: but I hope you're able to get some of this just to recap.

[00:14:35] [SPEAKER_00]: So the first step before you see your doctor, check your insurance, call them,

[00:14:40] [SPEAKER_00]: use their website to find out are these weight loss medications covered?

[00:14:44] [SPEAKER_00]: If they're not covered, then you may need to figure out,

[00:14:48] [SPEAKER_00]: you may need to go to your human resources to see if they can start covering these

[00:14:51] [SPEAKER_00]: medications or based on a prior authorization, you can make sure when you see your doctor that

[00:14:56] [SPEAKER_00]: you give them all the information they need as far as your weight loss history,

[00:15:00] [SPEAKER_00]: what medications you tried. And not only do they want the what

[00:15:03] [SPEAKER_00]: medications you tried, they also want the dates. So if you can write that down,

[00:15:07] [SPEAKER_00]: the dates of when you tried your medication, that will be extremely helpful.

[00:15:10] [SPEAKER_00]: So they can put that in the prior authorization. The hardest, the one thing that sometimes

[00:15:14] [SPEAKER_00]: these prior authorizations do get denied is because the doctor's office didn't have

[00:15:19] [SPEAKER_00]: everything. They didn't see that you were on Fentermine and Contrave and Casimia prior to

[00:15:24] [SPEAKER_00]: you starting trying to get Wigoby. And so they're just using the information that's in front of

[00:15:28] [SPEAKER_00]: them. So it's important to make sure your doctor knows that and then that's in the note

[00:15:32] [SPEAKER_00]: and they can add that to the prior authorization. Once the prior authorization comes back,

[00:15:36] [SPEAKER_00]: if it's approved, you get your medication. If it's denied, then you get an opportunity

[00:15:40] [SPEAKER_00]: to write an appeal letter to see if it can get appealed. You can get templates online

[00:15:45] [SPEAKER_00]: on how to appeal it. Also, you can also give your doctor a sample letter that they can

[00:15:52] [SPEAKER_00]: utilize for them to do it. Sometimes, depending on how busy they are, they may actually just copy

[00:15:57] [SPEAKER_00]: and paste and put the relevant information in it and that at least help you that they know

[00:16:02] [SPEAKER_00]: which information they need versus them saying this patient needs this medication and here's

[00:16:07] [SPEAKER_00]: my signature. So I hope this helps. The other thing I would say, it is important to advocate

[00:16:12] [SPEAKER_00]: for yourself, advocate for your fellow employees. If you need to, if you're on Medicare or

[00:16:18] [SPEAKER_00]: Medicaid, advocate at the level of your state government and also your federal government

[00:16:23] [SPEAKER_00]: so that we can get more people covered because not only are we're seeing really great results

[00:16:29] [SPEAKER_00]: where people are not only losing weight but their health complications are improving

[00:16:33] [SPEAKER_00]: and that helps people down the long run to live happier, healthier lives because of the

[00:16:39] [SPEAKER_00]: fact that they're weight controlled. I thank you again for listening today's episode. If you

[00:16:46] [SPEAKER_00]: have any questions, any topics you want me to cover, please feel free to leave that in the

[00:16:50] [SPEAKER_00]: comments. I'll be happy to create an episode just for you and I look forward to seeing

[00:16:56] [SPEAKER_00]: you all next week again on the Back on Track, Achieving Healthy Weight Loss Talkcast.

[00:17:01] [SPEAKER_00]: All right guys, have a great rest of your day and don't forget to like and subscribe

[00:17:04] [SPEAKER_00]: and share with us. See you next time.