GLP-1 Medications

[Aimeedyan]

I started on a compound GLP over a year ago and saw absolutely ZERO effects for months. I was so disappointed. It was only after I scaled up quite a bit did I see anything, and it was incredibly slow.

Realizing my insurance might cover it, my PCP submitted Wegovy for approval and it was approved for weight loss at 100%. I stopped seeing any changes so he recommended Zepbound. Switching meant completely starting over with the lowest doses so again, took a few months to see anything but I finally did!

Then my insurance stopped covering Zepbound and forced everyone to Wegovy.

So I had to go back to low doses of Wegovy, 4 weeks at a time, to get back to the level that had semi-worked prior.

I've been sitting at 2.4 for months now. Some weeks, it feels like it's doing nothing and other weeks I feel the effects. I'm down 65 pounds since Nov 2024, so clearly it's not been rapid! I still have another 20 to go, and I'm putting in extra work to try and get there.

I have no symptoms, no pain injecting Wegovy or Zepbound (I prefer abdomen), and my insurance covers it. It's been a huge win for me and I'm grateful for the help and support.

 

[disneychrista]

It's basically all just a numbers game with insurances. If they think that they will make more money, spend less money, etc. overall if they don't cover something that they aren't required to cover, then they probably won't cover it.
I didn
Once the patents expire and if/when the generics get cheap or at least affordable, I would expect the coverage rate to increase significantly

Yeah I am sure eventually there will be a generic. It didn't even dawn on me that it wouldn't be covered at all. I figured it would be covered at the name-brand price.

 

[Tatebeck]

For most people they and their employers pay for the insurance (though for some it is covered in part by the government (Medicare) or entirely (Medicaid)).

So patients and employers (and yes the gov't) pay the insurance companies, then those insurance companies (who are for profit) try to keep as much of that money as possible and only pay out what is necessary

It's just not doable right now. There are an estimated 100 Million obese people in the USA. At the average cost of around $1,000 per month, it would cost the insurance companies 100 Billion Dollars Per month to cover everyone on a GLP-1.

They aren't willing or able to do that, and even if they did want to, guess what, everyone's insurance would have to increase in cost by around $1,000 per month to cover it so the insurance companies stay positive.

 

[disneychrista]

For most people they and their employers pay for the insurance (though for some it is covered in part by the government (Medicare) or entirely (Medicaid)).

So patients and employers (and yes the gov't) pay the insurance companies, then those insurance companies (who are for profit) try to keep as much of that money as possible and only pay out what is necessary

It's just not doable right now. There are an estimated 100 Million obese people in the USA. At the average cost of around $1,000 per month, it would cost the insurance companies 100 Billion Dollars Per month to cover everyone on a GLP-1.

They aren't willing or able to do that, and even if they did want to, guess what, everyone's insurance would have to increase in cost by around $1,000 per month to cover it so the insurance companies stay positive.

But doesn't most insurance cover bariatric surgery?

 

[leebee]

My insurance covered my bariatric surgery (gastric sleeve) in 2016. I was in the hospital for 4 nights and it cost me $100 for my copay.

My insurance will NOT cover tirzepatide or ozempic unless it is for morbid obesity with at least one co-morbidity. I didn't qualify as my bariatric surgery took me out of those categories. Right now I am paying $208 a month for the tirzepatide and a $100 monthly membership fee (otherwise it'd be $333 a month with out the membership). I am fortunate that we can afford to do this.

I lost 110 pounds after having the sleeve (took about a year) and held it there for about 7 years. I got lazy, picked up some old, bad habits, and gained almost 35 pounds. I decided I didn't let them cut out my stomach to regain the weight, so started on 2.5units, weekly, of tirzepatide in August. I am up to 5 units and have lost 39 pounds in seven months. My health counselor said I am one of the most resistant-to-loss people she's ever worked with, but we are both happy with my progress. I don't want to increase the dosage any more than I have to. She also put me on levothyroxine to help bring my thyroid levels into a more optimal range, which I think has helped, too. I was hoping for more rapid weight loss but overall it's been effective. I'd felt I'd lost the "restriction" of the sleeve surgery, which meant that I was eating larger portions, which led to the weight gain (and just being lazy and self-indulgent too often). That restriction feeling is now definitely back since I've been taking the tirzepatide. I'd like to lose another 20-30 before weaning off of it. The only side effect I've had is some constipation, so I take miralax once or twice a week. I have no injection site pain. I self-inject with doses I draw up (so not the pen). The needle is about 1cm long (so less than a half-inch) and is about the diameter of a hair, so I have no pain at all when doing the shot; I pinch up some belly fat to the side of my navel and just pop it in!

 

[C&Jx2]

Does your insurance cover the cost of the GLP-1 for weight loss? It looks like my insurance, Blue Cross, does not.

It's not the insurance company itself, but the plan you have. I have Empire Blue Cross and it is covered. Maybe check out some other supplemental insurance plans and crunch some numbers?

 

[Tatebeck]

But doesn't most insurance cover bariatric surgery?

For a few of the most overweight individuals who have failed almost all other weight loss options and/or meet certain requirements, have certain comorbidities and show that they know how do eat correctly afterwards, then yes they do. So a much smaller number of patients.

And then that is a one time surgery and one time cost. Even if it costs 12,000 or 24,000 (equivalent to 1 or 2 years of a GLP-1 right now), that is still much cheaper long term than paying $1,000 per month for every obese patient that wants it for 20ish years until generics come out and then a few hundred dollars per month for the rest of the patients' lives since most patients just stay on the medication.