A professional in-home caregiver loses her coverage for being zipbound. He soon realized that getting it back wasn’t easy.
“I was like: ‘What am I going to do? Hopefully I can continue to keep this weight off.'”
— Deborah Finley, 50, of Lodi, California
Deborah Finley, 50, of Lodi, California, said her weight started to worry her in the early days of Covid. That’s when he noticed that many people who were on ventilators or dying had something in common: obesity.
“It was a scary time,” he said. As a single mother, she feared “that I wouldn’t be here for my daughter.”
Finley had sleep apnea and non-alcoholic fatty liver disease and was prediabetic. His pulmonologist suggested bariatric surgery but Finley’s insurer wouldn’t cover it.
She exercised and watched what she ate, but she wasn’t losing weight and her mental health suffered.
He told his doctor: “Look, I weigh 223 pounds. I feel like I’m hitting this wall. I don’t know what else I can do.” That’s when he suggested the GLP-1 drug Zepbound for obesity.
Finley said he still has a lot of work to do to get healthy. But the medicine helped. Her sleep apnea improved dramatically. He lost weight.
Then her insurance plan stopped covering Zepbound for weight loss at the end of last year. This has become common because GLP-1 drugs are expensive for health plans and employers.
“They started sending out notices to all patients,” Finley said. “And they said: ‘Look, we’re pulling this drug. We’re giving you 90 days’ notice to figure out what you want to do.’
From 2025 to 2026, 12 million people were in the plan Exclusion of coverage 12 million for Zepbound and had plans that excluded Wegovi, another GLP-1, according to Research by GoodRxA website that helps patients get discounts on prescription drugs.
If you find yourself in this situation, these tips may help.
1. Read the coverage fine print.
Although many plans don’t cover GLP-1 drugs just for weight loss, they may make exceptions if you have other conditions.
So was Finley. He learned that his insurer would cover Zepbound if it was used to treat obstructive sleep apnea, or MASH, a fatty liver disease. GLP-1 is also covered for people with type 2 diabetes.
You can work with your doctors for eligibility conditions, he said Caleb AlexanderProfessor of Epidemiology and Medicine at the Johns Hopkins Bloomberg School of Public Health.
Undiagnosed diabetes is “probably the scenario that allows someone to go from not being eligible to being eligible,” he said.
Since Finley’s sleep apnea and testing showed the medication helped, he learned it could still be covered with a prior authorization—you have to get approval from your health insurance before it’s covered. A medical expense.
Finley said her physician told her a prior authorization was on file, but when she tried to refill her prescription, the pharmacist told her Zepbound had been denied.
2. File an appeal – and get some help from your doctor.
Don’t give up if your medication is denied, he said Catherine VarneyDirector of Obesity Medicine for UVA Health, a health system affiliated with the University of Virginia in Charlottesville. Sometimes your insurer will rely on the appeal, if you make a good case.
Finley made several frustrating phone calls and finally went digging through his online medical records.
“I had to do my own investigative work,” she said.
Those records showed that Japbound was indeed denied. Her doctor previously applied for approval, but it wasn’t granted, because her insurer said there wasn’t enough data to back up the request. Somehow, her health information, including sleep apnea test results, didn’t reach the right people.
Finley eventually got his hands on the 17-page report and received a little help from ChatGPT to write an appeal, showing that the drug was necessary for him based on his diagnosis and covered by his policy.
This type of application can be a lot of work. Fortunately, many doctor’s offices will help and know how the system works, Alexander said.
“I don’t think patients should be expected to navigate these waters on their own,” he said.
3. Document your care carefully.
Sometimes you may have to file multiple appeals if the first one fails, he said Tracy Zeveniachvice president of advocacy and research at the nonprofit Obesity Action Coalition, which receives financial support from drugmakers including Zepbound maker Eli Lilly and Wegovi producer Novo Nordisk.
Zvenyach also recommends keeping precautionary records. Some plans require something called step therapy, which means patients have to try and fail another drug or treatment that their doctor wants them to take.
“Keep a history of other medications you take so you can provide documentation for the need for step therapy,” she said. “Document date of participation in any nutrition and physical activity program or membership.”
Finley filed an appeal on Feb. 4, and although he expected a hearing within 90 days, it wasn’t scheduled until mid-June.
He said it was stress because he hadn’t been able to get a new injection of Zepbound since mid-January.
4. Look for discounts if you’re paying out-of-pocket.
The drugmakers that make Zepbound and Wegovi sell the drugs at a discount to people who pay out of pocket instead of using insurance. (Try discount sites like TrumpRx or GoodRx.)
Even with discounts, drugs are not affordable for everyone. If you are a Health savings account Or a flexible spending account, you can use to pay for them with pretax dollars.
5. If you’re considering compounded GLP-1s online, look for red flags.
You may have seen advertisements for affordable off-brand obesity medications prescribed by online providers. These are compounded products—that is, made by specialty pharmacists rather than drug companies
Compounded drugs are prepared using the same active ingredients as brand-name drugs. But they are not approved by the Food and Drug Administration.
look for Quality and safety issuess. Check out the National Association of Boards of Pharmacy Online Pharmacy Verification Tool. Make sure the pharmacy prepares your medication Licensed in your state. If it is not, it cannot comply with inspection or other laws.
After stretching his remaining supply of Zipbound as long as possible, Finley is taking a compounded version of the drug while he continues the insurance appeal process.
6. Be persistent. And remember to breathe.
Being told no by an insurer is crazy. But Alexander says you often have other options.
“If any application we make fails, there are other treatments we can use,” he said — such as drugs like Contrav, or a cheaper combination of generic naltrexone and bupropion.
UVA Health’s Varney, who consults for Eli Lilly, said it would not give up trying to cover GLP-1. “Take a breath, but go right back to it,” he says, adding that GLP-1s are superior to older drugs on the market.
Alexander said he thinks obesity drugs will eventually become affordable — even cheaper. Statins, which are used to treat high cholesterol, were once expensive and difficult to cover. Now, Alexander notes, they’re generic and often cost just a few bucks.
“I know it’s hard to imagine,” he said. “But there will come a day when we no longer see these access barriers for GLP-1.”
Healthcare helplines help you navigate the health system barriers between you and good care. Send us your tricky question and we can tap a policy sleuth to puzzle it out. Share your story. The crowdsourced project is a joint production of NPR and KFF Health News.
KFF Health News A national newsroom that produces in-depth journalism on health issues and is one of KFF’s core operating programs—an independent source of health policy research, polling and journalism. Learn more about KFF.
this Article appeared first KFF Health News and is republished here under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License.
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Previously published at kffhealthnews.org
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