Comment by wormius

Comment by wormius 3 months ago

80 replies

My ACA insurance (because I was unemployed) covered Rybelsus (pill form, which is a much higher dose due to lack of absorption through the stomach), then in like October or November they said "nah" and said "go to Ozempic" I had just completed my first two sets of increases before the final uppage to be on the stable dose, when insurance said "Nah." So my doc RX'd Trulicity to see if they would cover that, which, for some reason they also didn't. I haven't had the time or energy during the holidays to deal with it, so now I'm dealing with increased hunger from going cold turkey off these things all because of bullshit micromanagement from shitty insurance companies on the market place.

If this makes it better and easier for companies to actually pay out for this I am 100% for it, there should not be a constant jerking about for what is or isn't paid. Also - this wasn't for weightloss (which I assume would have been Wegovy approved), this was for diabetes, and it was under control with Rybelsus, and I assume Ozempic, though we were still in the process of building up to it (I was on max dose of Rybelsus and I'm pretty sure I needed the max Ozempic as well). If they had given a reason for the denial it'd be one thing but it was just a blanket denial.

I just hope this makes it easier for folks who need it to be able to obtain it.

dbg31415 2 months ago

100% agree.

Insurance companies shouldn't get to pick and choose what drugs are in or out.

I was at a company, and Wegovy was covered.

Then randomly I got an email from HR, "Your medication is no longer covered."

The fuck is my insurance company doing telling my HR what medication I'm on? Even if they didn't say it outright, it wouldn't be hard to figure out giving the drugs that came off the list that were paid for that quarter. =P

Going cold turkey on these drugs is hard... like the doctors tell you that once you start taking them, you really aren't supposed to stop taking them. Or if you do, you have to do so gradually.

The drugs mimic the feeling of being satisfied from being full, by overloading your system with a synthetic version of that hormone that makes you feel that way.

Now... imagine going from "my parents used food to control my behavior growing up, and 40 years of bad behavior cemented that conditioning in place, so now it takes a lot of food to make me feel full / content," to "Oh this is nice, thank you drugs! Now I don't have to eat so much!" to "You're on your own, kid! And by the way, now that your body was used to the drugs, virtually no amount of food will make you feel full / content now. Let's see what happens!"

Fucking insurance companies. People are nothing but pre-existing conditions and behavioral patterns. It shouldn't be up to the insurance companies which ones they elect to cover. "Oh, did you think smoking was cool as a kid? Too bad, hope you die from lung cancer!" It just shouldn't be on them to choose.

  • alluro2 2 months ago

    I know it's a worn-out stereotype to point out, but from an European, I just hope you realize how jarring it sounds that there is a medication that a doctor determined you need, and TWO companies - entities driven by and existing exclusively for profit - are involved in deciding and communicating with each other on whether you will get it or not.

    I do think that this should still actively be regarded as scary and abnormal, even if it's the norm for so many people in the US.

    • slowmotiony 2 months ago

      Crazy right? Here in europe they just tell me that my medication isn't covered and I have to pay the whole price for it - if I don't like it, I can switch the government and move somewhere else.

      • pavlov 2 months ago

        It’s not like you can just switch insurance companies in the US. Most people have healthcare coverage through their employer.

    • graeme 2 months ago

      Does your country cover ozempic for obesity? In Canada we don't for non diabetics.

      Americans get more drugs covered on average is my impression.

      • hellcow 2 months ago

        Americans get no drugs covered--at all--unless you're over 65, have insurance through your employer, or pay thousands for insurance yourself (and often thousands more to meet your out-of-pocket deductible each year).

        I would take the default of "some" coverage over "no" coverage any day.

      • sergers 2 months ago

        I don't take it but did look into it.

        If anything getting it for diabetes got harder now.

        Canadian employers sunlife insurance.

        If you were prescribed it before the influx(not specific date) it was covered for diabetic purposes and still covered.

        Now if you want to apply sunlife says NO, but you can get your doctor to send us these forms with additional info about the diabetes diagnosis and need and may be covered.

        On the flip side theres a local diabetic that has been getting multiple high dosage units covered, but doesn't actually need them or take them

        Flips them for $200 cad each to people looki g for weightloss.... (230-280cad in a pharmacy with prescription no insurance)

      • wormius 2 months ago

        Only for diabetes. Wegovy is authorized for weight loss. There are other GLP agonists that are also authorized for diabetes. I'm not sure if there are other formulations for weight loss.

        The US does allow for "off-label" prescriptions. The question then is : will your insurance pay for it. In my case, even though I am diabetic, they wouldn't cover Ozempic, or, apparently even Trulicity, which is just absurd (or Rybelsus which is the oral form of Semaglutide which they DID cover for a full year before putting me on Ozempic for like 2 months, and then denying (after the "new formularies" are approved and I get to be forced and switch to a med they still claimed to cover but not, apparently - I'm assuming they want me to appeal and give a whole run around on that.

        But yeah... Technically it's for Diabetes only, but if you have good insurance, they'll probably hand out for any reason (see: "Hottest Celebrity Weight Loss Drug" for example; maybe that's changed now that Wegovy is released/authorized for weight loss)

    • Cumpiler69 2 months ago

      IT IS a worn out stereotype. I'm also European and here the doctors are also limited by the national health insurance company on what medication and treatments they can prescribe you due to cost reduction pressure. Their hands are also tied except not by a private corporation but by the government.

      Often you'll encounter the infamous "these tests or procedures aren't covered by the national insurance anymore so you'll have to pay out of pocket", or they're covered, but the nearest appointment on the national insurance is 15 months away, at which point you'll either get better or you'll be dead.

      My boss recently moved from Germany to the US and was pleasantly surprised how much better the diagnostic, treatment and medication options are for his child who suffers from some rare mental disorder that's basically ignored in Germany by comparison. US seems to always be on the cutting edge of medical research and treatment which of course comes at a cost since research is very expressive.

      • pavlov 2 months ago

        Your boss is presumably a high-value employee at a prosperous company. They will have good health insurance, but that’s not the norm for most people.

        When I worked for Facebook in the US, it was conspicuous how doctors would run extra tests on me because the health insurance was paying for everything and anything. That’s not balanced either because less fortunate people pay for that in their insurance premiums.

    • matthewdgreen 2 months ago

      Ozempic in Europe seems to be cheap, under $100 in many cases. In the US it costs 10x or more that. So as much as I hate to defend insurance companies, it's not just them.

      • NeutralCrane 2 months ago

        It is just them. The way insurance works in the US is that insurers negotiate with pharmaceutical companies to get steep rebates so that they are paying far less for the drug than its list price, typically much closer to what you might pay in other countries. If they can't come to an agreement, they won't cover the drug. Sounds reasonable. But in practice, what happens is that if a pharmaceutical company simply cuts the list price to what the rebate would be anyway, the insurance company ends up dropping them from coverage. This seems counter-intuitive, but it happens for two reasons.

        First, the middle-men who negotiate and develop the formularies for insurance companies, called pharmacy benefit managers, get a cut of the reduced cost. So they make more money from a drug being $1000 and rebated to $100 than they would from the drug just being $100 all along. The pharma company makes the same amount per unit, $100, but they are much more likely to get onto an insurance plan if they go through the sham of marking it up to $1000 and then cutting it down.

        Secondly, extremely inflated list prices that get rebated down simply mean that it becomes that much more critical for patients to pay for an insurance plan, because it is increasingly untenable to be without one.

        These "negotiations" that PBMs do have been closely guarded "trade-secrets" but pharma companies have in recent congressional hearings have essentially said this is the situation. This seems to be supported by the fact that in their financial reports for products like insulin, the actual profit per unit has largely kept pace with inflation over the last few decades, despite the listed price of insulin skyrocketing during the same timeframe.

        This is pretty much entirely the result of there not being a non-profit seeking government provided insurance option available to all in the US. If there is a reasonable alternative to private insurance that isn't engaging in the insurance cartel, no one is forced to use private insurance and the private insurers are actually forced to compete in a market. Completely socialized medicine isn't required, we simply need a Medicare-for-all option available to destroy the anti-competitive behavior that currently exists in the US insurance market.

        • hobobaggins 2 months ago

          We agree on the cause, but not the solution described in your last paragraph.

          If it was truly a free market, the federal government wouldn't be involved at all and I could buy insurance from any company in any state. It's because of the government's involvement that I can't buy insurance of my choice and preferred pricing from any insurer in any state.

    • pyuser583 2 months ago

      I get this sounds crazy.

      But what’s more crazy is the prospect your doctor is motivated by profit.

      Does that mean it’s less likely to be true?

      I’ve had some interactions with doctors that would chill your soul.

      “Here’s some long acting opiates. Take three a day for a month.”

      I’ve had doctors offer me antibiotics for the flu.

      I’ve been offered surgeries for conditions that don’t require them.

      I’ve seen doctors offer a week in the psych hospital over mild distress.

      • Lord-Jobo 2 months ago

        I mean yes but there is no solution to that problem, but there are many tried and true solutions to the other problem, so this just reads as deflection

        • pyuser583 2 months ago

          I’ve lived abroad and I’ve seen the solution: massive wait times for rationed care.

          I never had the problem of doctors pushing treatments I didn’t need in UK, Canada, Italy, or any of the other places I’ve lived.

          Seems to be an American thing, but maybe I’m missing something.

    • nipponese 2 months ago

      You think that is jarring? How about a drug company giving kickbacks to doctors to tell patients they need a drug?

    • phaedrus 2 months ago

      Four companies. The doctor's office which may be controlled by profit-optimizing administration, the big profit pharma corporation, the for-profit medical insurance company, and the company the insured works for who picks the available insurance plan(s).

      • NeutralCrane 2 months ago

        Doctor's office won't make money from prescriptions for a drug, and the pharmaceutical company will sell their drug to whoever will buy it. Both those entities also exist in non-US medication transactions as well, so I'm not sure it's relevant. The point is that the insurer and the employer are two extra middlemen.

    • fastasucan 2 months ago

      Don't forget getting an e-mail about it from HR??

    • ensignavenger 2 months ago

      You do realize that Euroean countris also decide what drugs and procedures they will cover on their national health plans too? Because you have a more limited set of options, your doctors will know what is covered and only recomend tose options, but it doesn't mean there aren't things that aren't covered.

      • alistairSH 2 months ago

        At least the set of approved drugs is known. In the US you don’t know until you try to fill the orecription, then it becomes a 4-way game of telephone (patient, MD, pharmacist, and insurance) with each trying to outlast the other.

  • nextaccountic 2 months ago

    > Then randomly I got an email from HR, "Your medication is no longer covered."

    > The fuck is my insurance company doing telling my HR what medication I'm on?

    Isn't this a straightforward HIPAA violation?

    • MajimasEyepatch 2 months ago

      No. HIPAA is rarely straightforward, and in any event it’s not uncommon for employers to have some degree of access to claims data. In a case like this I assume the company self-funds the plan.

      • nextaccountic 2 months ago

        That's wild; HIPAA mainly exists to protect medical data from employers (among other threat actors) in the first place

    • hypeatei 2 months ago

      I'm 99% sure HIPAA just applies to medical personnel (i.e. nurses, doctors) so they can't outright share private information. Third parties (i.e. your mom or insurance companies) can share it all day without violating HIPAA.

      It does not protect your medical data whatsoever.

  • Spooky23 2 months ago

    The insurance company is the face, the villain is your company. Most bigger companies are self insured. These drugs are expensive and blow up plan costs when everyone is on them.

    A relative has a self-insured Cigna plan that randomly fucks with you. The company hired another company to argue with them on your behalf. End of the day, Cigna is administering the plan they established.

tracker1 2 months ago

I had some really bad side effects on those meds... was on for over three years when I realized that was causing my gastroparesis and other issues. I felt like I was starving 24/7 for 8 months coming off. I wouldn't ever go back. Throwing up fermented crap nearly daily isn't fun, let alone the pain and nausea.

Beijinger 2 months ago

I partly agree with Kennedy. Ozempic will not make America healthy again. You will have to look into lifestyle choices.

This being said, if you want to go the medication route, there are not patents for medications in India. You could try to obtain it from India: https://dir.indiamart.com/impcat/semaglutide-tablet.html

I am not an MD and this is not medical advise.

QUESTION: If I live in the US in state XZ, what is the best, easiest way (zoom?) to get a valid prescription to order drugs from Mark Cuban? https://www.costplusdrugs.com

  • criddell 2 months ago

    > Ozempic will not make America healthy again

    Will it help a significant net number of Americans be healthier? If so, then it should be made available to those people.

    > You will have to look into lifestyle choices

    That's not being questioned, is it? Who doesn't understand that exercise and eating well is better than not exercising and eating garbage all day?

    • Beijinger 2 months ago

      You were obviously not able to understand my argument.

      Ozempic treats a problems (overweight) and might prevent problems further down the road (diabetes, high blood pressure, heart problems etc.) with trade offs like higher risk for specific cancers.

      It does not treat the underlying cause ob obesity. One that might be highly processed food and Kennedy, whatever you think of him, stated this correctly.

      Where in my post do you see that I said that Ozempic should not be made available? Please work on your reading abilities.

      • mullingitover 2 months ago

        > It does not treat the underlying cause obesity.

        Obesity is caused by compulsive excess calorie intake. That’s precisely what Ozempic treats.

        Kennedy is a grifter who profits from quack medicine. Ozempic, because of its effectiveness, threatens the supplements industry which is rife with quack cures for obesity. This is the reason he’s against it.

  • op00to 2 months ago

    Ozempic is only effective with lifestyle changes. The medication makes those changes easier. You should understand the effects of medication before you spout falsehoods.

ddorian43 2 months ago

Just do keto diet. Assuming T2D. Its the easiest disease it fixes.

Some people cant have it all in life. You gotta sacrifice. The carbs in our case.

Source: I do it for other reasons.

  • solresol 2 months ago

    When I last looked up the literature, Keto diet was one of the least effective interventions.

    That is, if you follow it, I'm sure it works.

    But the vast majority of people drop out of keto diets very quickly. So it's lousy advice and an unsuccessful intervention.

    It's a bit like saying to a patient "you gotta sacrifice -- you should doing 3 hours a day of cardio". If they do follow through with it, it will work. But the vast majority of people won't be able to maintain doing that.

    • mgiampapa 2 months ago

      I started keto in June of 24, lost 50lbs and added a compounded version of Ozempic in November to get through the holiday season with a little extra help. I'm on a fairly low dose, 50mg/week, and it's working tremendously. I've lost another 25lbs up to now and it's about 10x times easier to stick with keto, macro logging, and calorie tracking.

      I feel like even with keeping my calories to about 1500/day I'm just fine, and the cravings for sweets and over indulging just aren't in my head.

      • shlant 2 months ago

        > "When I last looked up the literature"

        Responded to with

        > anecdote

        I'm happy you have found something that works for you but the diet tribalism on this site is getting old. At least it's good to see the initial Keto comment getting downvoted to oblivion.

        • mgiampapa 2 months ago

          I don't think there are any studies yet combining keto and glp inhibitors. At least I can't find them. So yeah, you get personal experiences.

      • loeg 2 months ago

        > I'm on a fairly low dose, 50mg/week,

        50mg is a huge dose of Ozempic. 2.4mg/week is common.

        • mgiampapa 2 months ago

          Apparently I didn't math the math, I'm taking 1.25mg/week. I was measuring in units (.01ml) and the concentration is 2.5mg/ml.

    • ddorian43 2 months ago

      There are different keto diets.

      The epilepsy version is indeed hard to maintain, but can be life changing (increase life quality in epilepsy, bipolar, schizophrenia etc)

      The T2D version is way easier. If you studdy it or get a coach, you will know all the pitfalls. But its like therapy, you need to want it yourself. Cant be forced into it.