GLP-1 Medications

[Christine]

And I know plenty who can't. It just depends on if the patient is considered to be on a "government funded" plan or not. As you say, they can have a job in/adjacent to the government but their position still be using private insurance and sometimes those can still be eligible. But it depends on a coupon by coupon basis.

I mean, I work for the federal government, which pays for a share of federal employees' insurance. Everyone in the federal government has access to the weight loss drugs with all the usual authorizations. No one has been denied solely because they work for the federal government. They do get denied because they chose a very restrictive plan or the plan they chose only pays for the GLPs in certain situations. While another plan within the federal government pays for it with no problem (but you probably have a higher premium).

I am also on Tricare and they are very clear they don't pay for GLP-1s for weight loss.

 

[Tatebeck]

I mean, I work for the federal government, which pays for a share of federal employees' insurance. Everyone in the federal government has access to the weight loss drugs with all the usual authorizations. No one has been denied solely because they work for the federal government. They do get denied because they chose a very restrictive plan or the plan they chose only pays for the GLPs in certain situations. While another plan within the federal government pays for it with no problem (but you probably have a higher premium).

I am also on Tricare and they are very clear they don't pay for GLP-1s for weight loss.

And I mean, I am a healthcare professional who literally bills these coupons as part of my job and I actually dispense these medications regularly.

Soooo... Like I said if the coupon they are trying to use considers them to be "government funded" and the coupon isn't set up to run with gov't funded insurance then they 100% can and will stop the coupon from running through. The insurance plan itself can of course choose whether to cover it or not, or the patient can choose to pay full price, but the coupon can be stopped from working for the claim.

An easy Ex: A service member/their family with ONLY Tricare (which is pretty common), will not be covered for it on the insurance as you say, AND coupons may stop them from using them as well, so your claim that "Everyone in the federal government has access to the weight loss drugs with all the usual authorizations. No one has been denied solely because they work for the federal government" isn't quite correct.

And yes, I do see other plans (that are not Tricare) get flagged and coupons stopped for the aforementioned "government funded" insurance issue. Just because your plan is not flagged doesn't mean you can apply that to all plans.

 

[Christine]

And I mean, I am a healthcare professional who literally bills these coupons as part of my job and I actually dispense these medications regularly.

Soooo... Like I said if the coupon they are trying to use considers them to be "government funded" and the coupon isn't set up to run with gov't funded insurance then they 100% can and will stop the coupon from running through. The insurance plan itself can of course choose whether to cover it or not, or the patient can choose to pay full price, but the coupon can be stopped from working for the claim.

An easy Ex: A service member/their family with ONLY Tricare (which is pretty common), will not be covered for it on the insurance as you say, AND coupons may stop them from using them as well, so your claim that "Everyone in the federal government has access to the weight loss drugs with all the usual authorizations. No one has been denied solely because they work for the federal government" isn't quite correct.

And yes, I do see other plans (that are not Tricare) get flagged and coupons stopped for the aforementioned "government funded" insurance issue. Just because your plan is not flagged doesn't mean you can apply that to all plans.

When I say "everyone in the federal government" I don't mean service members. I am solely talking about federal civil servants. All of those plans function like private insurance and do not fall under the government funded plans such as Medicare/Medicaid/Tricare. I have it myself, I've used coupons for drugs, I asked the questions to the pharmacist as well as called the FEHB health fund managers because I was concerned about the government verbiage on Eliquis/Xarelto coupons I needed to use, was told by both that FEHB plans are not in the category of "government funded" insurance. Now, there are about 28 different plans for an employee to choose from at all different prices and I'm sure that some of those plans aren't playing in the GLP-1 game. But I do know that BCBS, MHBP, Aetna, GEHA, and the Foreign Service ones are. Kaiser? Nope, at least as far as the Kaiser people have told me--they can't get it.

 

[Tatebeck]

When I say "everyone in the federal government" I don't mean service members. I am solely talking about federal civil servants. All of those plans function like private insurance and do not fall under the government funded plans such as Medicare/Medicaid/Tricare. I have it myself, I've used coupons for drugs, I asked the questions to the pharmacist as well as called the FEHB health fund managers because I was concerned about the government verbiage on Eliquis/Xarelto coupons I needed to use, was told by both that FEHB plans are not in the category of "government funded" insurance. Now, there are about 28 different plans for an employee to choose from at all different prices and I'm sure that some of those plans aren't playing in the GLP-1 game. But I do know that BCBS, MHBP, Aetna, GEHA, and the Foreign Service ones are. Kaiser? Nope, at least as far as the Kaiser people have told me--they can't get it.

As I said, I 100% have had gov't plans (that weren't Tricare) that triggered coupons to not work. Whether the people programming/running the claims on the back end for the drug companies and their coupons were being overcautious in their consideration as to what constitutes an excluded gov't funded insurance, I cannot say. All I can say is that I have seen some government job insurances work with coupons that say gov't excluded, and I have also seen some that did not work with coupons that say gov't excluded.

It 100% lies with the pharmaceutical companies offering the individual coupons and the processing companies (usually PBMs) that they contract with to process the claims on the back end. Whether they are programmed 100% correctly as to which plans to include/exclude vs what is legally allowed I cannot say. I can just attest to how they actually work in practice.

Basically: we can always try to bill it, but the companies' computers then tell us if they will allow it to go through or not