Zepbound Not On The Insurance Formulary-But It Was Approved

[+ Gar1eth]

Zepbound which is approved as a medication for moderate to severe sleep apnea is not on my insurance drug formulary.
 

So I  was very excited about this new Medicare Bridge Program which started July 1st where if you have a Medicare Drug Plan of some type, and need one of the GLP-1's for weight loss you can get the medication for $50 a month outside of the drug benefit of your plan.  Previously Medicare Plans by law weren't allowed to cover GLP-1's for weight loss although they would cover them for diabetes 

But my excitement turned to despair when I found out that if you had moderate to severe sleep apnea, you weren't eligible for the Bridge Program. It felt like I was in a Catch-22 situation. I didn't qualify for the. Bridge Program because of my apnea, but Zepbound wasn't covered on my insurance. I called up the helpline for the Bridge Program. But it was a call center located (I'm fairly sure) outside the United States. I explained about my situation, but they didn't seem to understand the concept of a drug formulary. They advised me to call my insurance company. I didn't have much hope. But I did (actually I had called the insurance company about a month or a month and a half ago and they had said even though it wasn't on the formulary that Zepbound might be approved by going through a prior authorization process. But it didn't sound like a certainty. So I wasn't sure if it was worth it to go through all that it as I figured why would they approve a non-formulary drug). 
 

I ended up calling the insurance company again. This time when I told the agent that I had sleep apnea, he seemed to think that me getting approved for Zepbound would be a sure thing so I had my sleep study results sent to my endocrinologist. The endocrinologist ordered the medication. The insurance wanted proof that I had sleep apnea. The endocrinologist sent them the proof. And the insurance company okayed my prescription for Zepbound.

The stupidity (at least for people on my insurance) is that there are lots of drugs listed in the formulary that require prior authorizations. So if the Zepbound can be easily approved even when it's not on the formulary, then that  makes me think the insurance deliberately doesn't have it on the official formulary list due to it's expense (about $1000) per month so far. Maybe they are hoping people will see it's not on the formulary and won't even attempt trying to get an exception for it to be covered. If I had known how easily it would be approved (or even approved at all), I would have been on it months ago. Plus I've hit the out of pocket maximum on my drug plan for at least the last three months. So I wouldn't even have had to pay (and am not paying now) anything for the Zepbound. Once January rolls around, I won't be able to afford it as it will be in the top tier of my plan. 

Edited 3 hours ago by Gar1eth