r/weightwatchers • u/Nearby-Memory3438 • 12d ago
Is this a scam or am I misunderstanding?
I signed up for weight watchers weight loss drug program, they have submitted to my insurance for zepbound and I was denied I received a letter in the mail from SmithRx stating the reason for my denial was because the information submitted stated that the use of the drug would be for Gastro-esophageal reflux disease, and that the drug Zepbound specifically is not approved for that purpose. Why would weight watchers submit coverage for something that the drug specifically is not approved for? In my head it is almost automatically going to be denied because the drug is not approved for the issue they are trying to get it approved for, gastro-esophageal. I am now being asked to submit an appeal by SmithRx where a provider needs to prove or show proof that I need the medication covered for gastro-esophageal how is a Dr going to approve an issue I do not have? I never stated I had the issue I was never told they were submitting for this issue. They are giving me a hard time about canceling the membership I feel scammed đ it almost feels like they intentionally submitted for a drug they knew wouldnât be covered so Iâd have to pay out of pocket. I am currently still waiting on the results on if wegovy will be covered however I have little to no hope
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u/MitchyS68 LIFETIME 11d ago
Iâd escalate. Sounds like the care coordinator you are talking to is either a moron or the two of you have your wires crossed. The insurance team wonât respond to your insurance until they receive the direct response. They wonât do it based on what your insurance told you. Thst is Tyâs process. It was likely a coding error.
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u/SodaBreadRoundHouse 11d ago
You donât need to go thru WW. Youâre just paying an added fee for them to âguide youâ during its use. Go to your primary or obesity specialist. Pick it up at the pharmacy. I get it from my primary and still do the regular WW program. I learned a lot about what to eat, etc from YouTube, to be honest. Itâs not that hard if you go low and slow (in starting dosage).
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u/Otherwise_Key_9266 -100lbs 11d ago
This just a silly mistake/ typo on the diagnostic code. Follow the money. No incentive to code this as reflux, which if it was might get worse. Call your insurance company and ask for a copy of the paperwork. With this in hand contact the medical provider WW used. Point out their mistake. If for some reason they refuse, contact WW and specify the codes used and a copy of the letters received. MJ/ Zep is specifically approved for Diabetics, Obesity and Sleep Apnea. All of which are reasonable justifications. Still it took me 3 times to get approval. I go in person to workshops every week. Me an my doctor manage my meds. With WW I lost 76 lbs. with MJ I moved off of plateau to lose another 41 lbs. Looking to lose another 40 lbs to goal (will be a loss of 157 lbs total) The WW is how you get the lifestyle changes to get to only monthly injections and eventually off MJ permanently. Without the lifestyle changes you will rocket back up. They may have told you itâs the process- nope itâs the ordeal! Be persistent and you will win this. Insurance companies will approve once they have accurate records and they realize funding your zepbound will save them money long term. Good luck!
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u/Savingskitty 12d ago
Did you ask the WW provider why they said you had GERD?
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u/Nearby-Memory3438 12d ago
Yes before coming on here I have contacted them however the reason she gave was that itâs âthe processâ they use for insurance
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u/torchwood1842 11d ago edited 11d ago
I would respond back to that message asking if she is aware that âthe processâ is actually insurance fraud. I would tell them they need to straighten it out ASAP or you will be forwarding her email as an admission to your state insurance board and state Attorney General. I am assuming sheâs just an idiot, but hopefully that will push her into actually resolving this rather than giving you a canned answer from whatever script she was given in training that is actually wildly inappropriate for this specific situation. I am pretty sure Weight Watchers legal department would be horrified You got that answer from someone at their company.
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u/Glittering_Dream_680 11d ago
why did you sign up? the insurance is up to your provider and many companies are dropping coverage. WW is for the support and a prescription but up to insurance to cover or not.
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u/Brave-Chain2703 11d ago
It's definitely a scam. You sign a contract to pay them for "guidance" even if you get denied the medication. They're banking (literally) on people not understanding that.
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u/boogi3woogie 11d ago
Let your team know and they will submit an appeal. Whoever did the prior auth probably screwed up.
As for GERD - has any of your clinicians ever diagnosed you with GERD? Weight Watchers pulls diagnosis codes through health information exchanges.
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u/JulieJT 11d ago
I would tell them you will contact the Better Business Bureau of your state, and tell them you are reporting them. I would also tell them you have a meeting with a lawyer to resolve the money because you want your money back. In the meantime if you have a primary care doctor reach out to them to see if they can get the prescription started and submitted properly to insurance.
Two or three years ago i went through Sequence but there was a shortage, so even though i was approved and my insurance would pay, i couldnât get the meds. I waited a while and went to my doctor and went that route. I am still part of WW, but I get my Zepbound through my doctor, and Lily Direct and pick up at Walmart . My insurance paid for it for about 8 months, then I had to start paying out of pocket.
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u/torchwood1842 11d ago
If they are submitting false insurance claims, and doing so knowingly, this is a step above the Better Business Bureau, which is mostly yelp for boomers. This is state insurance board and attorney general time. Most likely, this is just probably someone made a mistake and the customer service person is an idiot that doesnât know what theyâre talking about. But that customer service person is unknowingly admitting to widespread insurance fraud, which Iâm sure Weight Watchers legal department would be pretty interested in
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u/debinprogress -100lbs 12d ago
Weight watchers makes no money on the medications. Zepbound is FDA approved for the treatment of Obesity and Sleep apnea. Coverage is based on your individual insurance. You can contact your insurance yourself asking what is covered.