I chose a plan because a drug I’m taking is NOT on the plans list of drugs that require PA and IS on the list of drugs that are covered. The use could be considered off label. The insurance company is denying coverage.
@kenth If you’re talking GLP-1 drugs, you’ll need to have your provider show why it’s medically necessary if you’re not T2D.
You’ll also likely have to go through a step-program before they’ll give you the Ozempic/Wegovy/Zepbound/Whatever GLP-1 new hotness people are clamoring for this week. And even then they may still NOT approve you for those drugs because you’re not T2D.
@mooneyto I was on Ozempic with my previous Medicare Part D plan. I only switched to this company because a PA wasn't required and I thought it would be easier. Laughs on me.
@kenth Yeah unfortunately with the costs of these drugs being so high, many commercial insurance plans pretty much decided they were not going to cover these drugs for off label uses.
Medicare also doesn’t cover Ozempic if it’s not for T2D so if you’ve been using it for weightloss… sorry?
Try hitting up r/ozempic. There’s usually a poster that has resources to clinical trials you can participate in possibly but you have to wash out of the drugs I think for 90 days.
@kenth No chance for approval for weight loss. Coverage for weight loss is prohibited by Medicare part d law. You will have to pay out of pocket for it. Most insurers are requiring type 2 diabetes indication for financial reasons. People taking it for weight loss were responsible for huge increases in costs.
@kenth You are not taking the medication for an approved indication but for an experimental one. It's not uncommon for coverage to be restricted to approved indications.
@kenth Just the way it is. Medicare doesn’t usually pay for off label use. They will cover it for on label use. If your doctor can prove the case for it through peer review studies then you’ll be fine.
