u/strongerthenbefore20

Background

\* My goal is to get one of the popular weight loss injection medications, with my first choice being Zepbound. Unfortunately, my insurance does not cover Zepbound for weight management.
\* However, I have been diagnosed with a severe case of sleep apnea after taking an in-home sleep test, for which I have been trying a CPAP for about a year. While it has reduced my AHI from 45 to 5 when I use it, I have trouble tolerating the way the mask feels on my face, so I can only wear it for 2-5 hours a night, averaging about 4 hours. I have already tried two different masks. I also currently have a BMI of 31.
\* While Zepbound is not covered by my plan, Mounjaro is. I tried submitting a claim for Mounjaro through my doctor for weight loss, but while the doctor approved it, it was rejected because I do not have type 2 diabetes.
\* I spoke with Optum customer service, and they told me I should try submitting a Formulary Exception Request through my doctor for Zepbound.

My Questions

1. If I submitted a Formulary Exception Request with all the proper paperwork, how likely would I be to get approved?
2. Armodafinil is covered through my plan for sleep apnea. Will I need to try this first before the insurance will consider letting me use Zepbound?
3. How long does the approval process usually take?
4. If I get denied, are there any further steps I could take?

Background

* My goal is to get one of the popular weight loss injection medications, with my first choice being Zepbound. Unfortunately, my insurance does not cover Zepbound for weight management.
* However, I have been diagnosed with a severe case of sleep apnea after taking an in-home sleep test, for which I have been trying a CPAP for about a year. While it has reduced my AHI from 45 to 5 when I use it, I have trouble tolerating the way the mask feels on my face, so I can only wear it for 2-5 hours a night, averaging about 4 hours. I have already tried two different masks. I also currently have a BMI of 31.
* While Zepbound is not covered by my plan, Mounjaro is. I tried submitting a claim for Mounjaro through my doctor for weight loss, but while the doctor approved it, it was rejected because I do not have type 2 diabetes.
* I spoke with Optum customer service, and they told me I should try submitting a Formulary Exception Request through my doctor for Zepbound.

My Questions

1. If I submitted a Formulary Exception Request with all the proper paperwork, how likely would I be to get approved?
2. Armodafinil is covered through my plan for sleep apnea. Will I need to try this first before the insurance will consider letting me use Zepbound?
3. How long does the approval process usually take?
4. If I get denied, are there any further steps I could take?

• My neck size is 19, and all of the regular shirts I've tried only go up to XXL, which only go up to an 18.5, leaving me unable to button the top buttons. Big and tall shirts work, but they are much too big for the rest of my body.
• While I have time to make minor adjustments to whatever shirt I buy, I don't have enough time to have a fully custom-made shirt prepared.

• My neck size is 19, and all of the regular shirts I've tried only go up to XXL, which only go up to an 18.5, leaving me unable to button the top buttons. Big and tall shirts work, but they are much too big for the rest of my body.
• While I have time to make minor adjustments to whatever shirt I buy, I don't have enough time to have a fully custom-made shirt prepared.

Specifically for a man’s suit