My insurance denied my Zepbound refill
I was feeling optimistic last week. My Zepbound journey is going well. With two months of 2.5mg under my belt, I was in a groove. I was managing the one side effect I seem to have (mild constipation) and was happy with my rate of weight loss (averaging a little more than 1.5 pounds per week).
Plus, there’s been an added bonus of this medication: reduced inflammation. I previously had a moderate amount of pain in my knees and some in my left hip and both ankles. For whatever reason, being on this medication has reduced that pain significantly. Life is good!
Related reading: Everything you need to know about Zepbound
A curve ball: My insurer denied Zepbound refill
I guess life couldn’t just let me bask in those good feelings without throwing me a curve ball. On Saturday – the day I expected to pick up my third box of Zepbound 2.5 mg – I got a text from my pharmacy: “We have a question about your RX. Please call us.” Uh-oh.
Seconds later I dialed the pharmacy and the pharmacist explained that my insurance company denied coverage. What? Why? Ugh!
If I wanted to pick up the medication, the price wouldn’t be the $35 I usually pay. Instead, this Zepbound refill would cost $550. The pharmacy had already applied the manufacturer’s savings card to reduce the cost from the $1,060 retail price. The pharmacist couldn’t tell me why the insurance company declined coverage and recommended I call them next.
Here’s what Express Scripts told me
I hopped on a call with Express Scripts and talked with a representative who honestly sounded emphatic and sorry that this was happening to me. He said that he’s received many calls like this one because the coverage nuances for Zepbound and other GLP-1 drugs can vary so much from plan to plan.
He told me that my plan would only cover two boxes of 2.5mg Zepbound since Eli Lilly suggests that all patients titrate up to 5mg after the first month on 2.5mg. Now that I’m on my third month of Zepbound, the insurer wants me on 5mg.
However, my doctor and I are comfortable at 2.5mg. I experience virtually no side effects (score!) and I’m losing weight at a good rate (about 1.6 pounds per week on average). Our feeling was, “Why move up when you’ve got a good thing going?”
I explained all that to the rep who was understanding. He told me that my doctor would need to call them to ask for a “quantity limit override.” He sounded optimistic that a phone call would do the trick. I thanked him for the information and hung up so I could reach out to my Weight Watchers Clinic care team.
A bumpy week with my telehealth clinic as we tried to solve this problem
This all happened on a Saturday. Normally, I can get in touch with my Weight Watchers Clinic care coordinator on the weekend. But, she was out of the office on vacation. The portal greeted me with that information and said that someone filling in would address my message on Monday. Ugh!
The clock was ticking. I had one more Zepbound pen, which I was due to inject on Monday. The longer it takes to solve this refill problem, the less buffer time I’ll have to ensure I can get the medication in time for my next shot on the following Monday. I was nervous.
I wrote a message to my clinician asking that she call Express Scripts to request the quantity limit override so I could remain on 2.5mg. I explained the time element and implored her to act quickly on this matter.
I didn’t hear back from the fill-in care coordinator until 8 p.m. on Monday, but she assured me she’d get this authorization in the works. I checked in on Tuesday but nothing had happened yet.
Escalating my concerns at Weight Watchers Clinic
On Wednesday morning I was nervous and annoyed. Weight Watchers Clinic hadn’t yet called Express Scripts. This was now five days after my initial attempt to get help. I felt that wasn’t acceptable, so I escalated my concerns. A senior care manager messaged me. She called Express Scripts and they told her that I needed to go to 5 mg. While she was on the phone with them, I received an automated call from Express Scripts to say my override request was denied and that they’d send me a letter explaining why. Sigh!
The Weight Watchers Clinic care manager got back in touch with me and explained that I needed to pay out of pocket for 2.5 mg this month (and all future months I’m on it) or move up to 5mg. I told her I’d need to think about it overnight and would get back to her. Nothing is ever simple.
Researching what ‘drug quantity management’ means
At this point, my nerves were frayed. As all of this was going on, I started to hear from other Zepbound users that they were having trouble finding the drug at their local pharmacies. Oh no. Was it really a shortage due to a lack of available medication or a distribution issue with the system being taxed after Oprah’s special on GLP-1 weight loss drugs? It doesn’t really matter. If we can’t get these medications when we need them, it’s a problem.
I decided to log in to Express Scripts to see if the denial letter was in the portal yet. It was and the reason for denial just made no sense to me:
“Coverage for additional drug quantities is provided when more than two consecutive doses are missed and re-initiation of treatment is needed. Additional coverage cannot be authorized at this time.
We based this decision on the prior authorization criteria for: 144339 Weight Loss – Zepbound Drug Quantity Management Policy – Per Days.”
It would have been helpful if Express Scripts had included the policy they referenced above but they did not. But the letter did include information on how to file an appeal, which I will do.
Paying out of pocket this month
By now, it’s Thursday, six days after the initial RX denial and four days before my next scheduled shot. I knew that my only recourse was to appeal the Express Scripts denial decision but that would take time. I likely wouldn’t get an answer by Monday when I needed to take my shot and I didn’t want my pharmacy to give away that box of Zepbound 2.5 mg to anyone else.
I decided that for this month, I would pay the out-of-pocket cost of $550. If I win my appeal, I will be able to submit a claim to get reimbursed for $515 of that cost. I know I am very lucky that I can invest in my health in this way. Not everyone is in that position and my heart goes out to anyone else that’s been in this situation and has been forced to move to a higher dosage before they wanted to or be forced to miss a dose.
The appeal process
To figure out how to appeal this decision, I called Express Scripts and asked the rep to explain the letter I got. You know when you talk with someone in customer service and you feel like this must be their first day? Yup, the conversion went like that. I asked her to explain why the coverage was denied and she just read the text on the letter but couldn’t really explain the why.
She told me that my doctor or I could appeal. That’s something that my Weight Watchers Clinic care coordinator wasn’t told when she called.
I have more questions that I need to get answered but I didn’t feel this rep could do that. I plan to call back and dig for more information on policy 144339 while my care team works on a revised prior authorization on their end.
I’ll report back in a future post to let you know how this all turns out.
What to do if your insurer denies GLP-1 coverage
If this happens to you and your GLP-1 refill is denied, call your insurer and ask them to explain why. They will also send you a formal denial letter, which should be available in your online portal. Then ask them to explain how you or your doctor can appeal the decision. Be your own best advocate and call back again and again if you need to. This is your health we’re talking about and I worry that random or hard-to-explain rules are messing with people’s care plans and that’s not acceptable.
The wrap-up
Has your insurance company denied a GLP-1 prescription after you received an initial prior authorization?
I’d love to hear about your situation so I can learn as much as possible about insurance denials in the hope of helping others navigate similar scenarios. Email me or post on the Shots to Shed Pounds Facebook page.
