Episode 239: Why did my GLP-1 get denied?

[00:00:00] Welcome back to the Back on Track: Achieving Healthy Weight Loss, where I help you get on track and stay on track with your weight loss journey. I'm your host, Dr. Alicia Shelly. So let's get started.

[00:00:27] Have you ever left your doctor's office feeling hopeful, like this is finally the thing that's going to help me to lose weight? You've had that conversation with your physician, you both have made a plan, you're ready to move forward, and then you get that message that says, your medication was enough. And just like that, everything shifts.

[00:00:51] Now you're frustrated, you're confused, and you may be even a little discouraged. You start asking yourself, did I do something wrong? Did I not try hard enough? Why is this happening to me? If that sounds familiar, then this episode is for you.

[00:01:10] Hello everyone. My name is Dr. Alicia Shelly, and I want to welcome you back to the Back on Track Achieving Healthy Weight Loss podcast. Today, we're going to be talking about something I deal with almost every single day, insurance denials for weight loss. And I want to start by saying this clearly. This is not a you problem. This is a system problem.

[00:01:38] So today, I'm going to break this down for you. We're going to talk about why denials happen, what you can actually do about it, and what your options are moving forward. Because I don't want you stuck. I want you to be informed and empowered. So let's start with the big question. Why does this happen in the first place? Because on your end, it probably just feels very random. But on the insurance side, it's actually very structured.

[00:02:08] One of the most common responses I get back from insurances, and it's really the most frustrating, is that this medication is excluded from the drug formulary or drug benefit. And basically what that means is that some insurance plans simply do not cover weight loss medications at all. Not because they don't work, not because you don't need them, but because the plan has decided.

[00:02:36] Obesity treatment is not a covered benefit. And this is where I see patients feel the most defeated. Because it feels personal, but it's actually policy. Because let's say if you had two different people that work at two different companies, but they have the same insurance carriers such as Blue Cross Blue Shield, UnitedHealthcare, or something else.

[00:03:01] And what you'll find is if one employer covers weight loss, then yes, that Blue Cross Blue Shield will cover it and there's no problem. But if the employer, the other person, the employer does not cover it, then it would be excluded. So in order for obesity medications to be covered, the employer who you work for has to opt in to covering obesity treatment.

[00:03:27] And I will say it's not the fact that you don't meet the criteria of weight loss because some medications require very specific diagnosis.

[00:03:37] For example, when it comes to weight loss, weight medications, you have to have a BMI of 27 plus a weight-related comorbidity of either type 2 diabetes, prediabetes, high cholesterol, hypertension, sleep apnea, or have a BMI of 30 and higher without any weight-related comorbidities.

[00:03:59] And even if you have the diagnosis of type 2 diabetes, they're medications that are specifically to help with weight but are specifically for type 2 diabetes. You have to have both in order for those medications to be approved. And even if the medication works for weight loss, in the case of type 2 diabetes, sometimes that's one way how we get it covered because they do have diabetes.

[00:04:22] Now, the other common response I get from insurances is, we want you to try such and such medications first before we approve the one your doctor recommended. Even if those medications are less effective, have more side effects, or you've already tried them before. This is what they call step therapy. But honestly, many patients feel like they have to step backwards therapy.

[00:04:48] Because if I want to use a GOP-1, why do I have to use this other medication first that does not have the same weight loss percentages? And that's maybe increased my blood pressure or do something that's going to hurt me or harm me than this other medication. And so it's very, very frustrating. And this is where details matter. Because many plans require proof of six months of lifestyle changes, documented weight history, higher attempts at weight loss.

[00:05:16] And if that documentation is not submitted just right, then that person will get automatic denial. And if you've been somebody who's been battling with your weight for years, you know, sometimes to have that proof that you did Weight Watchers for six months or that you're seeing a trainer for six months, sometimes that can be very frustrating. Or what if these are attempts or ones that you've made on your own and not necessarily with a medical professional? And let me sit here and tell you about a patient I recently saw.

[00:05:46] She had been doing everything right, working out consistently, changing her diet, showing up to visits. We prescribed a GLP-1 medication and it got denied. Her first response was, I guess I didn't try hard enough. And I had to stop her right there because that denial had nothing to do with her effort. It was because her insurance required six months of documented visits. And we were at month five.

[00:06:11] So each and every month I had to see her or my dietician saw her or my exercise physiologist saw her. And we had to document that we saw her so that at month six, we can be able to submit that. And if we skipped a month or she couldn't make it that month, we had to start all over. And when I think about it, that one month difference, same patient, same effort, same need. But because of the way the system is created and made, it makes it harder for her to get her medication.

[00:06:40] So I wanted you to hear this clearly. A denial does not mean you failed. A denial does not mean you didn't do enough. It simply means you hit a barrier in the system. So the next question is, what can we do about it? And let's talk about what actually helps because you do have options. The first option is to appeal the decision. And let me reframe this for you. An appeal is not begging the insurance. An appeal is advocating for your health.

[00:07:08] The appeal allows you to explain your medical history, highlight your risk factors, justify why this treatment is necessary. And I've seen appeals get approved, even after initial denials. I've even seen patients who call their insurance able to get it approved because just sharing with them their medical history. And this is where your care team matters. We want to clearly document your weight history, what you've done in the past, what prior treatments you've been on, what lifestyle efforts you made,

[00:07:37] what medical conditions you have, like hypertension, sleep apnea, or PCOS. Because the stronger the story we tell, the stronger your case becomes. Now, and I'll be honest with you, this part is hard. Appeals take time. In fact, the average is around 30 days. And authorizations take time. And when you're ready to move forward, waiting feels so frustrating. But this is where consistency matters.

[00:08:03] So keeping showing up, keep documenting your efforts, keep the momentum going. Instead of thinking everything is on hold, shift to I'm building my case. That mindset shift alone can make a huge difference. Now, let's say you've appealed, you've waited, and it's still denied. What can you do next? There are now more self-pay options than ever before. Some of these medications offers have reduced pricing programs.

[00:08:32] So regardless of, you know, what your insurance is, whether it's Medicare or Medicaid or commercial, you can be able to get this medication for the same price. Now, it's not as pricey as it used to be. It used to be like $1,500 for these medications. But now it can start off as low as $149 to as high as $449, depending on which medication you take. So it is a little bit more affordable. And this can make treatment more accessible as well.

[00:09:00] Also, if you have commercial insurances, some companies offer savings programs or coupons. Don't always apply to everyone because everyone's insurance is different. Especially if you have a federal funding, then you can't necessarily use the manufacturer's coupons. But they're worth exploring. And just remember this, every option comes with benefits, limitations, and trade-offs. And there is no one-size-fits-all that's the answer.

[00:09:27] And the goal is to find the safest, most effective, and most realistic option for you. So if you take nothing else from this episode, I want you to remember this. You're not behind. You are not failing. You are navigating a very complicated and convoluted system. And that system has tons of barriers and has delayed. And yes, it can be frustrating. But it does not define your progress. Your effort still counts. Your consistency still matters. And your journey is still moving forward.

[00:09:57] Even when it doesn't feel like it. So keep showing up. Keep trusting the process. And stay consistent. Because you are stronger than you think. And remember, we are stronger together.