By: Ariel J. Warden-Jarrett, MD, FAAFP

“Doc, you really have to help me lose weight!”

Your doctor smiles at you and states, “Sure, let’s go over your options.”

You ask about Semaglutide because you saw TikTok video, and you have a colleague that lost 50 pounds on the injections. After an in-depth discussion, you and your provider agree to try Wegovy® (Semaglutide). You are so excited! But the excitement is short lived. When you go to pick up your prescription, you learn from the pharmacist the following:

1. Your insurance won’t cover it and it will cost you $1,200 per month out of pocket.
2. There is a back order as the demand has exceeded the supply.

You feel helpless, defeated and lost all over again. What do you do?

It is important to understand that your employer selects your benefits, but the insurance company also selects the medication formulary. They indirectly work together. Therefore, you cannot assume that individuals with the same insurance plan that work for different companies will have the same coverage.

1. If the medication is not covered on the insurance formulary or by the employer, check to see what needs to be done to see if you qualify for an “exception.” This process is often called a prior authorization. In this case, the treating provider appeals to the insurance company to cover the requested medication due to a specific medical necessity. Unfortunately, the process can take time, and with many medical offices experiencing staffing shortages, the process can take even longer.
2. Next, reach out directly to the pharmaceutical company to see if they have programs/coupons that you may qualify for in order to bring your out-of-pocket costs down.
3. Reach out to your employer to see if there are plans to cover weight loss medications. Maybe you are not the only one needing the medication. Perhaps if enough employees reach out, the employer may recognize the potential need and include the option during the next open enrollment.
4. Last but not least, reach out to your elected official and share your frustrations with trying to obtain access to medication that your provider prescribed. They may be able to use their influence to urge pharmaceutical companies to increase their production of certain medication based on the demand.

I have had several patients that went through steps 1 and 2. We were able to get the medication approved through a prior authorization. Each circumstance is different, but together we can work to help you reach a more desirable health outcome.