Health Insurance Lied about wegovy being covered.

Hey so this is long so feel free to keep scrolling if you want. I’ll try to summarize as best as I can.

Back in March, I called my third party insurance company to check coverage on Ozempic for PCOS and was told that Ozempic was only covered with a type2 diabetes diagnosis. They then recommended Wegovy to me and said that all I would need is a prior authorization from my doctor and it would be $50/month or $125/month for home delivery. They called Optum (our pharmacy benefits provider) to confirm. So, I scheduled an appointment with my doctor a few months out (since it is a specialist), arranged childcare, drove across the state to see my physician, stayed in a hotel, and got the prior authorization and prescription.

The prior authorization was immediately denied so I called and they told me that that was just part of the process and to submit an appeal with all of the same information and it would be covered. Weird, but okay… got my doctor to submit an appeal and then that also came back immediately denied. So I call to see what is going on and that is when they tell me that there is a plan exclusion and weight loss drugs aren’t covered. They also advised that further appeals would render pointless due to this policy exclusion. Naturally I was pissed because at this point it was 4 months later (and yes I checked – the plan had NOT changed in those 4 months) and NOW they are telling me it’s not covered? I have screenshots of my insurance company stating it’s $50/month and covered with prior auth.

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To further complicate things, this drug was also listed on the formulary provided by my husbands employer. The formulary states that it is approved with prior auth and has a quality limit. It does have a star next to it that says policy exclusions could apply but it doesn’t give any indication that that’s the case. My insurance company still to this day hasn’t been able to provide any policy exclusions or documentation that this is even an actual exclusion. I ended up calling HR to find out that this is an actual exclusion.

My health insurance company is now stating that they don’t have access to my benefits or exclusions and they rely on Optum to tell them that info. Which is a lie – Optum has confirmed that all benefit details come from my health insurance company and Optum will actually reach out to my insurance company if there is any confusion or clarification. So Optum should never have even been called to see if this medication was covered (although it does seem like they may have provided my health insurance with incorrect info back in March). To this day, if I call optum about coverage on this drug I am told it’s covered with a prior auth and when I call my insurance company they tell me they can’t access my benefits or exclusions and rely on optums internal system to check to see if a claim would process. I won’t go into why it’s popping up as approved for optum – that’s a whole other can of worms – but the important part is they should have provided me with an accurate representation of my benefits before dragging me down this entire process. This third party insurance company literally seems like it’s in a basement – it’s that shady and incompetent.

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I’m wondering if anyone has any ideas on where to go/what to do next. I presented the screen shots, call recordings to my insurance company and they say that since Optum provided them with faulty info they won’t provide an exception and I will have to take it up with optum. optum says that my insurance company is the only one who can make exceptions or provide policy exclusions and they should’ve been able to provide us the correct information from the beginning.

What do I do? I’ve been trying to find a lawyer in MN but I’m struggling to find someone who works with health insurance bad faith claims unrelated to anything workers comp related.

I don’t think it’s fair that they drug me down this path and I’ve spent months of time, money, time off work, arranged childcare, about 5-6 days total of time on the phone with optum & my insurance company just to be told $50/month was a lie and it’s actually $1700 a month but they will give me a discount plan of $1400 a month. Gee thanks. This can’t be legal. Please help.