Remember the excitement surrounding the introduction of GLP1s (Mounjaro, Wegovy and Ozempic) to the market? We were promised that as soon as an indication came out for weight loss, access to the medication would be solved.
Zepbound (Tirzepatide) was launched in December 2023, and the reality has fallen short of expectations. Despite the promising launch, we find our patients are still experiencing pushback from insurance companies regarding covering the cost of this medication.
These are the barriers to Insurance coverage we are seeing:
1. Many Insurance companies simply will not cover these medicines for weight loss. The drugs are not included in their Formulary
2. Time from prescription to actually receiving the medication can at times, take weeks.
3. All Prior Auths are denied on the first pass. Weight and BMI data and patient’s charts are not opened
4. Many patients are required to undergo 3 months of Wegovy or Saxenda before approval for Zepbound. Both of these medications are on a National Shortage List and are difficult to find.
What are some solutions?
What can you do?
1. Persistence. Continue to press your insurance broker, and your HR department to cover these medications
2. Learn what is on your Formulary and the criteria for receiving that medication. Know the Prior Authorizations procedures.
3. Make sure your chart includes everything you have done to try and lose weight. All medications you have been on, and exercise programs you have tried. Medical issues you may have (PCOS, High Blood Pressure)
4. Call pharmacies near you and ensure that they have your medications in stock.
What does Bridgeside do?
1. We complete a Prior Authorization and send it to your insurance company at the end of your consult. This is part of our service to you. We include chart notes and letters of Medical Necessity.
2. We complete an Appeal for you, with the information missing requested.
3. We will speak to your insurance Payor on the phone to answer any further questions they may have
4. We have been know to merge our patients with the insurance company for further discussions.
5. And we advocate for you
It is our hope, that as this medication becomes more available on the market the prices will go down and the coverage will increase. Don’t give up! Bridgeside is committed to working with you every step of this journey.
