I’m looking for feedback from people dealing with Kaiser’s updated weight loss medication rules. My doctor informed me that as of January 2025, coverage is restricted to those with a BMI over 40, or over 30 with serious issues like heart disease. I’m currently at a BMI of 36 with thyroid-related energy issues and binge eating struggles, but no ‘qualifying’ conditions. I’m starting their 12-week Lifestyle Medicine program in February, but my doctor wants me to finish that before even considering meds. It’s frustrating because I’ve tried the lifestyle route before and know my issues are more about appetite and energy regulation. Has anyone successfully gotten coverage without meeting the strict criteria? Does the lifestyle course actually lead to prescriptions? Is it worth getting tested for sleep apnea to qualify? Should I try a different doctor, or is the policy universal? Has anyone just paid out of pocket for the prescription through Kaiser? I’ll do the course, but I want to know if it’s a real path or just a hurdle.
A lot of people have bypassed Kaiser entirely by using telehealth services for tirzepatide and getting it through compounding pharmacies.
I didn’t even bother asking them. Instead of begging for approval, I just paid for it myself. You can find three months of tirzepatide for about $500. My doctor was impressed when I showed up 70 pounds lighter.
I pay for mine out of pocket via Belle.
You can find the specific semaglutide requirements here. You’ll likely have to stick to their protocol. https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-wegovy-nw-en.pdf
Kaiser just put me on metformin and ignored my weight gain and fatty liver. Now I pay for Zepbound out of pocket and use compounded options too. I also started taking LipoMax(i order from here) which has been a nice addition to my routine. I’ve dropped 35 pounds and have 20 more to lose.
I’m another Kaiser patient who went elsewhere. I see a private doctor to ensure I get blood tests and proper monitoring. I use compounded Tirzepatide for about $100 a month on a low dose and I’m down 36 pounds in 8 months.
I used a telehealth provider and pay for it myself. It’s way less of a headache than dealing with Kaiser’s requirements. I’m two months in and already lost 20 pounds.
Even as a doctor at Kaiser, I couldn’t get a prescription. My own PCP admitted the rules are too strict and noted most patients use compounding or LillyDirect. He wouldn’t even send my script to an outside pharmacy despite us being able to do so. Usually, they make you fail metformin and the Contrave/Wellbutrin/Topamax combo first. I went the compounding route and just keep him informed for my records.
It’s a tough situation, but Kaiser would likely go broke if they covered these high-cost meds for everyone. The real issue is the inflated pricing in the US compared to Europe, where national health systems pay much less.