If you have a better plan with better drug benefits like the silver plan with a lower deductible you won’t pay nearly as much.Anthem BCBS may cover weight loss surgery as long as your policy does not specifically exclude coverage. And because it’s so expensive and a specialty tier at $1346 a month I pay 40% of that but not to exceed $500. In order for me to get it covered under my plan I needed a formulary exception which is when the Dr writes on the Rx that its medically necessary but since my plan does not have Brand coverage It’s subjected to my deductible. I believe ozempic is on the formulary but Wegovy is not for most if not all Kaiser plansįor example I have the Bronze 60 Hmo and it only covers generic drugs not tier 4 or specialty brand name Im on Wegovy it’s not in my formulary. All of these Glp 1 drugs are specialty tier drugs. Hi! The formulary is a list of drugs that are covered under your specific plans drug benefits.Īnd Each plan has different coverage for all these drugs. Is there any hope we'd see Kaiser implement actual coverage for these drugs in the future in California? Kaiser North West seems to have a program in place since November 2022: kp-mounjaro-nw-en.pdf () What is the impact, if any, to your Kaiser PCP if you file a grievance in order to attempt to get coverage for these drugs? Is it truly something that's at the doctor's discretion or are their other forces at play behind the scenes? Some people claim to have filed grievances after their PCP declined to prescribe, and their grievance resulted in approval from Kaiser to cover their meds.ĭoes anyone have any insights into the process of getting GLP-1 drugs (Wegovy/Ozempic/Saxenda/Mounjaro) covered under their Kaiser plan? These reports came from patients in both Norcal and Socal. I've anecdotally seen several reports of Kaiser patients who have had success at not only getting their PCP to prescribe drugs like Wegovy and Mounjaro, but also to get a formulary exception in place so the drug was covered. He seemed supportive but lamented that the drug is non-formulary, and that Kaiser doesn't cover weight loss drugs anyway so at most he could write a prescription but it wouldn't be covered and I'd have to pay out of pocket. I had blood work done before and after my 4 months on Mounjaro and had a discussion with my Kaiser PCP explaining what I had done, and how it was very effective for me. I've felt the incredible positive impact of these drugs when I was able to get discounted Mounjaro for $25/month using their savings card last year, but it required jumping through a bunch of hoops (using 3rd party telehealth for the prescription, and going to an "affiliate" pharmacy which has the ability to bill Kaiser insurance in order to get a denial so the coupon could be applied). Unfortunately, it seems that most Kaiser plans specifically exclude weight loss drugs. With the rise of highly effective weight loss medications such as Wegovy and other GLP-1 receptor agonists, there is real hope for people who have struggled with obesity. Sharing personal experiences is acceptable, but always consult a qualified healthcare professional for medical advice. Please refrain from soliciting or providing medical guidance, diagnoses, or treatment suggestions. This sub is not a place for seeking or offering any form of medical advice. No low-effort, spam, or advertisement/selling posts or comments. All posts must be in some way related to the organization and the healthcare they provide.Ĭomments on posts need to stay on topic and not attempt to threadjack. This sub is for discussions around Kaiser Permanente. If you're being toxic or just here to cause trouble, you will be removed from the community. Remember, there is a person on the other side. Participate in good faith, be respectful, and do not insult others. Treat others as you would like others to treat you. r/KaiserPermanente is the only subreddit for your KP health care questions, concerns, and stories. KP focuses on providing high-quality, affordable healthcare services and improving the health of its members and the communities they serve. KP is one of America's largest not-for-profit health plans, serving over 12 million members across eight regions. We're the original unofficial subreddit for Kaiser Permanente (KP).
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