Mastodawn

Can some please explain to me why it is that your health insurance can deny you medication, even if your doctor says you need it?

https://lemmy.world/post/43865952

Can some please explain to me why it is that your health insurance can deny you medication, even if your doctor says you need it? - Lemmy.World

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?

actionjbone Mar 5

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.

cymbal_king Mar 5

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)

actionjbone Mar 5

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.

captainlezbian Mar 5

If that was the case we’d have one of the most efficient medical systems in the world instead of one of the least

ℕ𝕖𝕞𝕠 Mar 5

They can’t, they can only deny coverage for it. You can still get it paying for it yourself.

KuromiGirl04 Mar 5

Yeah, paying $200+ a week for a shot. In this economy?

I don’t know anyone who has that kind of money

I just went through this battle myself. And my insurance even approved it, but I’m traveling overseas for two months and even though they tell me my benefit covers a “vacation override” they wouldn’t approve it.

I asked the pharmacy how much it would cost to pay out of pocket. $1300 for 4 weeks, so $2600 to cover my trip.

Luckily my Dr was able to give me “samples” to get me through my trip.

Also, another thing that I learned in the past year. What your insurance will cover and how much they’ll cover changes depending on your history.

Spend a three day weekend in the ER/ICU and suddenly I DO need Ozempic and they’re giving me thousands of dollars worth of CGMs for free.

It’s all a cost/benefit analysis for them.

BurgerBaron Mar 5

The intended goal of conservative voters is to ignore your plight and they’d like you to die off screen.

Munkisquisher Mar 5

Here in NZ it’s less than usd $300 a month full cost, but usually funded by the govt.

ℕ𝕖𝕞𝕠 Mar 5

I’m not saying it’s right, I’m just saying it’s so.

Tollana1234567 Mar 5

imagine trying to get approval for biologics, which can thousands a month.

actionjbone Mar 5

Not always. Sometimes, companies won’t sell it to you if your insurance has denied it. They may say it’s because they don’t believe you can afford it.

Rhynoplaz Mar 5

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.

KuromiGirl04 Mar 5

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."🙄😒

Jack_Burton Mar 5

Unfortunately, the answer is to move to a country that’s not a shit hole and has universal healthcare. The next best is to do what you can to survive while you try to convince people to vote with you for a gov’t that will give you universal healthcare.

Right now? I can’t imagine what you’re going through and I really am sorry I can’t help directly. Your system is broken. Your gov’t has failed you. I really, truly and honestly, wish you the best and hope you find the help you need.

Pommes_für_dein_Balg Mar 5

Then you gotta pump those numbers up, those are rookie numbers!

(pls don’t)

starlinguk Mar 5

Three months for 350 is pretty good, here it’s 500 a month.

minorkeys Mar 5

Because the humans making money off health insurance don’t care that we suffer. Our wellbeing is absolutely irrelevant. That is why the Luigi is a folk hero right now.

Corkyskog Mar 5

Capitalism and actuarial science. Their models likely show that you are still young enough for them to keep you fat for a few years while the cost of GLP1s go down.

disregardable Mar 5

The reason is that doctors and pharmaceutical companies are also for profit, meaning they make money selling you treatments. This puts them in a position to use your condition to exploit both you and the company. The insurance company is balancing the cost of your preferred treatment versus the cost of other treatment and the benefits. You can work with your doctor to build a documented record of attempting to lose weight- see a nutritionist, start seeing a therapist for your food addiction, start going to weight loss meetings, exercise therapy for the morbidly obese, etc. These will also be helpful by themselves, because those drugs are only temporary. Like weight loss surgery, people regain the weight when they don’t do the work to address the underlying issue.

𝕱𝖎𝖗𝖊𝖜𝖎𝖙𝖈𝖍 Mar 5

This is what pushed Luigi to allegedly merc one of them

Not a newt Mar 5

What do you mean, Luigi was at my place playing xbox games when that guy got killed.

Can confiem. I was playong with both of them online, and Luigi and I were making lewd comments about lemmyng’s mom.

pinball_wizard Mar 5

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.

TrackinDaKraken Mar 5

Because the filthy rich don’t care if anyone dies.

OwOarchist Mar 5

They care if a rich person dies. My friend Luigi proved that.

pinball_wizard Mar 5

Allegedly.

Fubarberry Mar 5

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.

Tollana1234567 Mar 5

apparently you can use coupons for the pharmacy in amazon to lower the price evenmore. i wonder of goodrx works on it.

captainlezbian Mar 5

Clown ass country where we need coupons for medicine

Tgis article has some helpful tips if you haven’t tried it.

healthline.com/…/how-to-appeal-insurance-claim-de…

Also assuming you’re American look to see if your state has a Department of Insurance. I had a positive experience with mine when Geico was trying to pay me half what my car was worth.

A Guide To Successfully Appealing An Insurance Claim Denial

You can take these steps to help appeal an insurance denial. Knowing certain hacks and working with your healthcare team can help you get what you need for your health.

Healthline

obelisk_complex Mar 5

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.

sin_free_for_00_days Mar 5

Had the same experience. I ended up having my doctor write a prescription for wegovy pills and am just paying $200 out of pocket. I figure I’m at least breaking even by eating less. Only been a month so far.

whotookkarl Mar 5

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.

youtu.be/AZhCYisIQB8

Deny

YouTube

Brave Little Hitachi Wand Mar 5

This is the lore. I haven’t heard from anybody trying it, I hope OP will make the attempt and report back.

AmbitiousProcess (they/them)Mar 5

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.

Adulated_Aspersion Mar 5

And you can leverage that in your appeal letter.

Especially when you have a pissy provider who doesn’t like being told “no.”

uberfreeza Mar 5

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.

CileTheSane Mar 5

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?

whotookkarl Mar 6

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.

Because Fuck You, that’s why.

jakemehoff11 Mar 5

Mounjaro and Ozempic both have savings cards you can sign up for on their respective websites, as long as you aren’t on government insurance.

I had the same issue last year, my A1C was 6.9 and insurance denied coverage. I got the savings card from Lilly, had my doctor call in the script and BAM! 25USD for 12 weeks of Mounjaro.

I didn’t even need a prior authorization anymore. Apparently results may vary, but I got lucky. Try them both if needed. Stay vigilant!

KuromiGirl04 Mar 5

I am on government insurance.

Tollana1234567 Mar 5

they recently stopped covering glp-1 and similar for state subsidized healthcare, seems to coincide with it being lobbied against recently in congress.

EveryMuffinIsNowEncrypted Mar 5

Money and the power of “fuck you”.

:(

This sucks, and I’m sorry, but you missed one crucial thing.

Eat healthier, eat more fruits and veggies, cut out excess sugar, walk more, exercise more

Have you tried eating less? Fruits and veggies give you good nutrition, working out builds muscle, but the only thing you can do to actually lose weight is to eat less.

KuromiGirl04 Mar 5

Yes, i have in fact tried eating less

Pommes_für_dein_Balg Mar 5

LMAO @ “Have you tried eating less?”
What a ridiculous question.

Stay strong and I hope you can get the medication you need.

I mean it is pretty crucial.

Pommes_für_dein_Balg Mar 5

Assuming that someone trying to lose weight for 5 years never considered eating less is laughable and condescending.

It’s like telling someone with a severe substance addiction “You missed one crucial thing: Have you tried not doing drugs?”

True lol. It’s just that that’s usually the culprit. Eating less is really hard, and tons of people are addicted to food. I’m not trying to be the enemy here, despite what it seems. It’s the fact that OP didn’t say they tried eating less in their post, so that was what first came to mind.

And our bodies are just machines. We can’t create fat if were using the calories we consume. I don’t really get anyone who “tries” to lose weight for years. If you keep putting more food in your body than you need, your body converts it to fat. The idea of since “strange reason” that a body won’t lose weight is silly. There’s just no way for a body to keep weight on unless they are taking in more calories than they are using. So if OP can’t bear to eat less, they need to get really active. There really isn’t a mystery here. Its math. If you only add to the equation, the figure only increases. This is a willpower issue. … Or maybe we found the one obese American whose body defies caloric mathematics.

communism Mar 5

My weight varies around 50kg and there was a stretch of a few years where I tried bulking up to put on muscle. I found it very difficult and only got up to about 65kg where I plateaued (and it was damn difficult to get to that point—required an annoying amount of calorie-counting). I think my body is just naturally averse to putting on weight. It naturally follows that there are some people with the inverse problem, where their bodies naturally want to keep fat. I have friends who say they have this problem, and I have no reason to believe they’re lying; they know I wouldn’t judge if they just said they like eating and don’t feel like changing. There’s 8 billion people on Earth and plenty of genetic diversity among us. Of all the fat people in the world, you really think every single one of them is incapable of simply eating less? Or do you think I’m too stupid to decide to eat more food? Come on.

Just because a rock falls down doesn’t mean it “naturally follows” that some rocks fall upward too. There is no way to invoke a system that stores excess energy as fat if there is no excess. Could some energy that is actually needed get stored as fat? Okay, but… Not for long, as the body would need energy, since it isn’t getting calories. Unless it is getting calories from food.

I went from 175lbs to 125lbs in four months during divorce proceedings. My metabolism didn’t change. I wasn’t on a new miracle drug. I was depressed and didn’t eat, and I took up running a 3.2mi circuit around the bay where I live.

To your point, I bet OP’s diet would help you bulk up, just not likely with muscle. Chow a few gallons of ice cream each week. Eat American fast food three to ten times a week. Put cheese on everything. Ignore the “added sugars” part of the nutrition label. My weekly intake fits in a single shopping bag. I doubt OP can say the same. They weigh 2.5 times my weight.

Willpower is much harder to muster for a whole year, and its exceedingly difficult to avoid bad calories in this country.

communism Mar 5

Nobody can defy the laws of thermodynamics, but some people can be genetically predisposed to being fatter, just as some people are genetically predisposed to being taller. Plenty of skinny people (myself included) can eat through loads of fatty fried foods and not put on a single kg. Meanwhile you see a fat person eating all salads and they get told maybe they should eat fewer salads.

And even if it were entirely down to what you eat, calling it an issue of willpower is just insulting. Do you think people struggling with drug addiction just have a willpower issue? If OP is in the US (which I’m assuming she is from the described healthcare system), the food there is designed to be practically addictive and unhealthy. I doubt OP has a diet of cheeseburgers and doritos—it wouldn’t make sense for someone trying to lose weight to eat like that—but if she did, that’s clearly a social issue of both fast food companies under capitalism, availability of healthy food, and a US food culture centred around destroying your arteries. Sure, a drug addict could simply physically not pick up the needle, but they can hardly be blamed for doing so when there is an obvious material reason for them doing so, ie a chemical addiction.

Do you keep your calories under a certain amount every day? Myfitnesspal used to be good for tracking that. Now I use cronometer!

starlinguk Mar 5

For some people that “eating fewer calories” part might be only eating a few hundred calories a day because of insulin resistance (hello?), certain medications they’re taking (like beta blockers) or plain old stupid genes.

The average resting human body burns like 1200-1800 calories a day. So no, not a few hundred lol. If OP ate around 2000 they’d probably start to lose weight.

Pommes_für_dein_Balg Mar 5

Has it occurred to you that OP has heard advice like yours with varying levels of condescension literally all their life?
And they haven’t asked for weight loss advice in this thread. They asked for advice on accessing healthcare their doctor has deemed necessary.