Let me explain with my current situation. I am 22 F and I currently weigh 305lbs.
I am obese. Morbidly obese.
Even though I have been trying for 5 years at this point to lose the weight on my own. Eat healthier, eat more fruits and veggies, cut out excess sugar, walk more, exercise more, the whole kit and caboodle.
But I still am not losing the weight. I am still very fat. And I am worried that it will cause very serious health problems.
So I talked with my doctor and she told me “We need to get you on a weight loss medication. Let’s try Ozempic”.
But my insurance told us that they don’t think I need the Ozempic so they won’t pay for it.
So we tried Wegovy and Mounjaro. But my insurance still rejected our requests.
They’re saying because I am young, and I am a diabetic with good numbers, I dont need the weight loss meds and I can just lose the weight naturally.
But ive been trying to and it hasn’t been working. So that’s why my doctor prescribed me the weight loss med.
Why is this allowed? Why is it that your insurance can deny you a medication, even if your doctor says you need it?
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It’s quite simple:
They are money-grubbing assholes in an unregulated industry. Their goal is to make as much money as possible while hurting as many people as possible. Because if they hurt people, they can take their money and provide no service.
It’s legal because the government won’t make it illegal.
They argue that they are preventing waste and fraud by holding doctors accountable. Like “oh if we didn’t have this power then doctors would order so many unnecessary tests and prescriptions”
(Not defending them, just sharing what they say)
Yeah, and what they say is bullshit. Doctors prescribe the medicine people need.
They don’t care about fraud. They care about their profits. We shouldn’t repeat their excuses like that.
If that was the case we’d have one of the most efficient medical systems in the world instead of one of the least
The insurance company is going to have a doctor who said you don’t need it. They will try to hide who that doctor is, specifically what their NPI is, which can be used to personally identify the doctor who made the medical judgement against your doctor’s without having to provide further explanation than they’ve already given. Depending where you are they may have to provide more information when directly asked for specific evidences, or will suddenly change their rejection on the claim with a letter from an attorney asking for specific details in writing. They know hiring an attorney is expensive and bank on people not advocating for their rights & people with severe medical issues not being able to afford to.
And lastly a video of a surgeon being denied the NPI of the insurance’s doctors who are likely breaking the law hiding behind the idea that insurance doctors are so hated they need to hide their identity even from other doctors to prevent reprisal. She was blacklisted from United claims for this video and others like it.
The insurance company is going to have a doctor who said you don’t need it.
To add on to this, my psychologist told me that he’s had antipsychotic meds denied by a urologist before, because the insurance companies often don’t actually care what field the doctor is in. All they care about is getting to say “a doctor” reviewed it.
then they have teams to review the first insurance agent approved your medications, and sometimes a team to review that teams decision of said medication. they will do this til you give up.
And you can leverage that in your appeal letter.
Especially when you have a pissy provider who doesn’t like being told “no.”
I have a relative who is a doctor. Had a claim denied once from someone that was not a doctor. Next: denied by someone not actively practicing in the field. Then denied by a doctor with no experience in that specialty. Only after all of that was it approved. They’ve also been picky about order of operations, such as not covering an MRI because there wasn’t also an order for a CT.
This is the lore. I haven’t heard from anybody trying it, I hope OP will make the attempt and report back.
Isn’t the insurance approving the medication/procedure only after being asked for proof the denial was legally obtained evidence that the denial was illegal, and reason enough for a lawsuit?
I have no idea, it might be worth checking with a couple attorneys who specialize in healthcare to see if you have a case worth pursuing as many will at least do a quick consult to see if you have a case without charging. The legal system is setup for wealthy people and organizations though so I wouldn’t expect much without something like practicing completely outside of their area or pretending to be from another state or something more than a lapsed certification or making judgements from a kinda similar but not really the same specialty.
Oh, I know the answer to this one. It’s because we don’t have single-payer healthcare, which Republicans don’t want because they don’t want bureaucratic death panels of disconnected doctors denying people access to medication.
They’d much prefer to have bureaucratic death panels entirely disconnected from any medical expertise denying people access to their medication and for spurious reasons.
Monied interests have crafted a legal system that benefits them, not you.
I hate that this is happening to you.
Darknet Markets are booming with semaglutides because of capitalism’s greed.
This guy is so photogenic, it’s insane
he bulked up in jail apparently too.
The insurance companies want to make money.
There are no (enforced) laws prohibiting this behavior.
Very few insurance company decision makers are murdered in the street.
Change one or more of these, and you’ll get better results.
This is what pushed Luigi to allegedly merc one of them
What do you mean, Luigi was at my place playing xbox games when that guy got killed.
Can confirm. I was playing with both of them online, and Luigi and I were making lewd comments about lemmyng’s mom.
That was so rude, but also hilarious. It was a big lobby that night, but Luigi was really keeping everyone chill.
yep, I was there too.
Allegedly ☝️
Nurse here. Because in America our healthcare priorities are FUCKED that way. Getting worse every year too
isnt also because alcohol industry is lobbying against it, because omezpic also reduces your “desire” for addictions.
and McDonalds.
no way this skinny CEO eats that shit.
He swallowed some of the juice, he’ll taste that for weeks.
You gotta love the wince developing on the left side of his face as he chokes down his promo nibble.
no way this skinny CEO eats that shit
I think “Super Size Me” touched on this. Calories in the burger aren’t as impactful as calories in the fries and drink.
Money and the power of “fuck you”.
:(
Nunber 1: Ozempic is NOT a weight loss drug.
Ozempic is a diabetes management drug that has a potential side-effect of weight loss.
The reason that you are likely being denied for Ozempic by your insurance is because you likely lack the diabetes with the additional comorbidities. You shared that you are diabetic with good numbers.
If you had worse diabetes and additional issues (comorbidities) such as high risk for stroke or heart attack by (very) high unmanaged blood pressure, then you could appeal the insurance company to cover the drug.
Number 2: the struggle is real. I highly recommend you fight this and continue your weight loss journey. Diabetes is unbelievably complicating later in life.
US healthcare will go broke covering $350/mo drugs to counteract lifestyle choices. 15M already on this drug, that’s $5.25B a month.
Damn, so five whole days of the Iran war would cover it for a whole month for everyone?
It doesn’t cost $350/mo/person to produce these drugs. Manufacturers brazenly price gouge knowing no goverment body would retaliate.
This is a problem that can be solved by legislation and cutting out the middle-man(insurance companies) by expanding medicare for all.
Oh no! Not the health
careinsurance industry.Good. Fuck em all and replace the whole thing with a system that works.
Because your congressperson is bought and paid for and there aren’t enough people assassinating health insurance CEOs in the street to inspire them to change their ways.
You can get wegovy 28-day of the auto injectors through Amazon pharmacy for $200 a month without insurance. It still requires a prescription, but it sounds like you have that.
Obviously it would be better if your insurance would cover it, but $200 a month is better than the $600 a month some people are paying for ozempic/etc.
When signing up for insurance, you’ll want to check their approved medications. My wife was prescribed mounjaro for her diabetes, but most of the insurance plans we looked at didn’t have it listed as one of their approved medicines. It was one of the largest factors in deciding which insurance we needed to go with.
apparently you can use coupons for the pharmacy in amazon to lower the price evenmore. i wonder of goodrx works on it.
Clown ass country where we need coupons for medicine
My wife was prescribed one of those for her diabetes, and the insurance company STILL wouldn’t cover a dime. She was able to find a coupon for a three month supply for $350.
And see, that’s what my problem was
Yes, I am technically a type-2 diabetic, but i am a diabetic with good numbers, so my insurance is saying "oh we wont pay for those meds. You don’t need it."🙄😒
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Then you gotta pump those numbers up, those are rookie numbers!
(pls don’t)
Three months for 350 is pretty good, here it’s 500 a month.
Because everything in America is a privatized scam and the regulatory agencies are being completely dismantled
Sadly that’s only (or mostly) in America. Here we get whatever meds the dr says. Most common ones are subsidized by the government (via taxes yes).
My idea of Ameroca was already wild but finding out you gotta convince an insurance company you pay that you need medicine a dr prescribes is crazy.
Oh and we get pretty much all blood tests and stays for free. GP one day, scan/test the same day (different location but some have them next door) then back at the GP by the end of the week with results and get your meds. Done.
Sorry OP.
