Episode 242: Self-Pay, Savings Programs, and Smarter Strategies for GLP-1 Medications

[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.

[00:00:28] Hello, and welcome back to the Back on Track Achieving Healthy Weight Loss podcast. I'm your host, Dr. Alicia Shelly. Today, we're talking about something that so many people are struggling with right now, how I can actually afford weight loss medications.

[00:00:43] Because let's be honest, you finally decided to prioritize your health, you go to the doctor, and how long did it take to get that appointment to the doctor? And I know you were told you're a good candidate for medications like Wagovi, Zepal, Manjaro, Zempec. And then you find out that your insurance either does not cover it, or requires endless prior authorizations every six months getting something. Or it wants you to complete another program first.

[00:01:11] I've seen patients where they have to complete these online programs before the medication is covered. Or you have an out-of-pocket cost of over $1,000 a month because you haven't met your deductible. And honestly, this feeling can feel so discouraging. But today, I want to help you understand that you may have more options. We're going to break down the self-pay programs, manufacturer saving options, oral GOP-1 medications,

[00:01:41] and flexible strategies to lower cost, and how to think about long-term obesity treatment as well. So if you've been overwhelmed trying to figure this all out, this episode is just for you. But first, let's talk about the emotional side of this. Because I see this every single day in clinic. Patients often feel frustrated, ashamed, exhausted, or feel like somehow they failed because insurance won't cover the treatment.

[00:02:09] But I need you to hear this clearly. Obesity is a chronic medical condition, just like high blood pressure, asthma, or diabetes. And unfortunately, our healthcare system has not fully caught up yet. And when it comes to obesity treatment, cover it. So when insurance says no, that does not mean you're not deserving, or the medications wouldn't help, or your health goals don't matter. It simply means we may need to get creative and strategic.

[00:02:37] So why do these medications cost so much? Well, they are newer. This kind of came out over these last several years. And the medications like Wagovi, Zeppel, Manjarin, and Zepic are still under patent. So they don't have a generic brand name medication as of right now. And therefore, they're a little bit more expensive than maybe your generic medication that's been out on the market for 20 plus years.

[00:03:03] And these medications work on hormones involved in appetite, fullness, blood sugar, cravings, and metabolism. And they are highly effective. But because the demand is so high, and insurance coverage is so inconsistent, many patients are left paying out of pocket. Retail pricing can sometimes exceed over $1,000 or $1,200 or even $1,500 a month. And that's not realistic for most people.

[00:03:28] But thankfully, several companies now offer reduced self-pay programs. So let's break down some of the more common self-pay programs that we see. Option number one, the ZepBound self-pay program. ZepBound currently has one of the structured self-pay programs that comes through their pharmacy called Lily Direct. Typical pricing often looks like around $2.99 monthly for the 2.5 milligram dose,

[00:03:53] $3.99 for the 5 milligram dose, and then $4.49 for all higher doses. Now, pricing can change over time because it's going through the manufacturers. They actually set what the pay is and what the cost is. So this may be totally different by the time you go to get this medication. And so it's therefore important that you verify current pricing through their manufacturer, going online to their website to find out.

[00:04:19] But compared to paying over $1,000 retail, this can make treatment much more accessible for some people. One thing I like about this program is that patients can sometimes bypass the insurance headache completely, especially for people whose insurance excludes obesity medicine entirely. Now, let's talk about the Wagovi Penn self-pay program because it too has a self-pay program as well.

[00:04:43] But that price starts off at $1.99 for the first two months for new clients as far as using their NovoCare pharmacy. And it's usually the dose is 0.25 milligrams and 0.5 milligrams that are $1.99. After that, the price goes to $3.49 for the 1 milligram, 1.7 and 2.4 milligram doses. And then it's $3.99 for that 7.2 milligram dose. And this pricing is through the NovoCare self-pay pharmacy.

[00:05:12] And once again, pricing can change. So patients should always check the latest information. But this is significantly lower than what the standard retail pricing is. Now, the oral GOP-1 medications is an area that's evolving rapidly because many people are interested in GOP-1 medications and pill form. And honestly, for some people, this can be more affordable and a convenient option.

[00:05:36] So some of the examples that we see are the oral semaglutribe products like the Wagovi or Zimbab pill or newer medication like Fundale. These medications are typically taken daily instead of weekly injections. And their current prices may fall around $1.49 for the first two months and then $2.99 monthly depending on the dose and the program. Now, are they identical to injections? No, they're not.

[00:06:02] But for some people, they're easier to tolerate, easier to travel with, less intimidating, and sometimes more financially realistic. And remember, the best medication is often the one you can consistently access and sustain. So let's talk strategy because sometimes affordability is not just about the medication itself. So if you have an insurance, an employer that covers weight loss medications, make sure to use the manufacturer coupons and savings programs.

[00:06:30] And some patients don't realize they exist. They just go to the pharmacy and they just give them the price. But always check the manufacturer website. You can sign up, give them information, and they can give you a savings coupon to get the price down. Also, don't forget about the pharmacy discount programs like GoodRx because they have worked with the manufacturers to have coupons to bring the price down. And don't forget about all those savings coupon cards that you can get on their website.

[00:06:58] Now, the second strategy we can use is pairing medications with lifestyle changes. And this is important because the medication is a tool, not the entire treatment plan. The stronger your foundation with nutrition, movement, sleep, stress management, and protein intake, the more effective and sustainable the results may be. And then number three, think about the long-term instead of the quick fixes. I think this is one of the hardest mindsets to shift because many people will say, I just need this for three months.

[00:07:27] I'm just trying to lose about five to 10 pounds. But obesity treatment often works more like blood pressure treatment or asthma treatment or cholesterol treatment. It's a long-term management medication. And so when considering affordability, ask yourself, what can I realistically sustain over time? Because consistency matters more than perfection. And so I also want to encourage the listeners not to give up after one denial

[00:07:53] because sometimes prior authorization, appeal letters, documentation of medical conditions can help the insurance say yes. Sometimes adding that sleep apnea diagnosis or cardiovascular diagnosis, or even telling them that they're in a structured weight management program can help support approval. And we are starting to see more recognition that obesity treatment improves blood pressure, diabetes, sleep apnea, heart disease risk, fatty liver disease, and overall quality of life.

[00:08:22] So even though the system is frustrating right now, progress is happening. And you may see a complete difference in a year from now. So stay encouraged. Now, if you're listening to this episode and feeling discouraged because treatment just feels financially out of reach, I want you to know that you still have options. Your health is still worth investing in. And sometimes the journey just looks different than expected. And I'd recommend seeing your doctor so that they can be able to share with you what your options are.

[00:08:52] And just think about it. Maybe you can start with an oral medication. Or maybe you start with a self-pay program. Or maybe you appeal the insurance denial. And maybe you focus on just foundational habits while building towards treatment. And please don't interpret obstacles as failure. Because your health journey is not over because insurance created a barrier. If this episode helped you, please subscribe to the podcast, leave a review, and share this episode with somebody who's been struggling

[00:09:21] to navigate weight loss medications. And until next time, stay strong, stay committed, and stay consistent. And remember, we are stronger together.