Health insurance no longer covering Mounjaro, denying Ozempic for Diabetes
I have Anthem health insurance through my job. About a year and a half ago I was diagnosed with Type 2 Diabetes by Doctor A. Doctor A prescribed Metformin, which I had a horrible intolerance to. Every possible bad side effect, it seemed like. Shortly after Doctor A left that practice and Doctor B filled in. Doctor B confirmed my diagnosis of Type 2 Diabetes and prescribed me Ozempic. Prior authorization required trying Metformin again, which I did to no avail. After that prior authorization went through because I met the criteria of the plan’s formulary (Type 2 Diabetes diagnosis and intolerance to Metformin). Insurance covered Ozempic for a few months. A1C wasn’t responding as well as Doctor B liked to Ozempic so she suggested switching to Mounjaro. Prior authorization was required again and went through with no issue because I met the criteria of an official diagnosis of Type 2 Diabetes and insufficient response to Ozempic. I took Mounjaro for roughly a year and had great success. Dropped my A1C from over an 8 to a 5. After all that time Anthem changed their formulary and no longer covers Mounjaro. My doctor tried switching me back to Ozempic, which is covered by my insurance, but they have denied it twice and have now denied our appeal as well. They now say that I don’t meet the criteria because I don’t have Diabetes (despite approving three different medicines in the last year and a half to treat my Diabetes, one of which was the medicine I’m trying to get again) and that I haven’t tried Metformin, even though my intolerance to Metformin is the entire reason I ever got my initial prior authorization. I truly don’t know what to do. I have diabetes. It was being managed well by the medicine they won’t let me take. It didn’t get cured. It doesn’t get cured. It just goes into remission and will come back if left untreated. I’ve now been ~1.5 months without anything to treat my diabetes. My appetite has increased significantly. I’ve gained 30 pounds back in almost 2 months. I’m constantly thirsty. I’m actually scared of what will happen to me and the insurance just seems to be making shit up and contradicting their own earlier decisions to avoid having to pay for this medicine.
What can I do?