Exception Request Denial, of sorts-Thoughts?
So for those of you who have been on Zepbound for a while (over a year or longer), let me get your insights on this.
I've been on Zepbound since March 24. I went through insurance (BCBS FEP). I received a PA and for a time, insurance covered it, until they didn't (insurance stopped paying for all of it in October 25). Fine, whatever. I have still had my PA in place, even though I haven't been going through insurance since February 26 and have been self pay via Lilly Direct. (Oct-Feb, went through insurance and it was $500+, so I switched to LD.)
My PA is up in August 26, and of course, I received a letter from BCBS FEP, stating that they "did not approve your recent exception request". First, I didn't request one and I know my doctor's office did not either. I think its documentation on their end to CYA. (Basically a denial letter of use as prescribed by doctor because I did not meet medical necessity by not participating in weight management program and no documentation of trying prefered products, ie wegovy and saxenda.) I literally started Zepbound before it was a thing with insurance.
I've been going through Lilly Direct, and am considering a switch anyway for maintenance. That said, with the change of BCBS' formulary in October, and possible further insurance changes in the future of hopefully, one day pie in the sky coverage for this medication, would you appeal the denial? Even if the appeal is solely for record keeping purposes and a complete picture of your progress and insurance documentation of taking this medication?
Also, I was under the impression that, according to the drug cost estimator tool, a PA is no longer required for this drug under BCBS FEP. Is my understanding correct? (All questions I can ask BCBS, which I will call and do.) I am thinking of going with the appeal anyway because I feel like I have a good reasoning for it. Just wondering what others would do in the same situation? Thoughts?
Posted Aug 12, 2026, 2:05 PM UTC