I can’t tell you how frustrating it was to have to deal with insurance companies to get approval for a medication that my doctor wanted to put me on.
There’s a lot of nonsense that patients have to go through in our current health care system to get required medication approved by insurance companies, it’s just maddening sometimes. And I think the goal here is to get you to quit, wave a white flag and just get on with your life without the medication.Because they don’t want to pay for it.
My saga was based around trying to get on the GLP-1 medications, primarily for weight loss, but also to help control symptoms surrounding diabetes. One specialist had recommended that I put myself on the medications and wrote me a prescription for one of the best selling prescriptions on the market.
You should know that the medications are insanely expensive. And there is no way that I was going to start that medication without some help from my insurance company.
In fact, one doctor told me, I probably shouldn’t do it.Because while the benefits were clearly there, the costs were just prohibitive.
That first prescription was denied by the insurance company for payment.
The rationale given was that I had to try a different competing product before they would approve the first product. So I had my doctor write a prescription for the other product. That one was denied, too. This went back and forth, about four or five times each time being denied by the insurance company. What was so interesting was that one of the denials was based on the fact that my A1C was apparently not high enough to be approved for the medication.
So I suppose the insurance company would rather pay for my stroke in the emergency room rather than pay for medication, which could have some beneficial impacts in preventing the stroke in the first place.
I kind of gave up, and then I had an check-in with my knee replacement surgeon, who said that he works with a clinic called the “orthopedic weight loss” clinic (OWL) that has a lot of experience in working with the insurance companies and had gotten people approved for the medication for weight loss.
So I finally got an appointment with the OWL clinic. They attempted to get me approved for the same medications this time using different symptom codes. Two rejections later, I finally got approved for the medication that was equivalent but labeled differently by the manufacturer. (Zepbound is exactly the same as Monjaro but indicated to treat different symptoms by the manufacturer.)
So, the OWL clinic wrote a prescription for Zepbound and gave it a diagnosis code that somehow magically was approved by the insurance company. I started on the medication last week.
This saga has been going on for about six montha. And yet, it seemed that all I needed was to have the right medication brand with the right diagnosis code and voila the medication would be approved, or so it seems!
Why couldn’t they have said that at the beginning and saved us all a whole bunch of trouble?
What was also so interesting is that OWL clinic told me that if I had waited just one year until I was eligible for Medicare, that this wouldn’t be a problem at all that Medicare providers would approve the medication routinely.
I’m very fortunate to have decent medical insurance.And yet, it seems like the insurance companies are playing a game. They want to run you around and around in circles until you simply give up when trying to get important, medication approved.
I’ll leave aside for a future discussion.Why those medications are so expensive in the first place and a lot of it has to do with corporate greed.
Why can’t the government negotiate prices for commonly used medications like these?
The Tao of Steve 