(A tale of prior authorizations, pharmaceutical gatekeeping, and the doctor caught in the middle.)
It’s mid-afternoon, and my medical assistant is on hour four of her phone marathon with one insurance company. The patient has been on tirzepatide for a year, finally seeing improvement both internally and externally – better labs, improved sexual function, better digestion, and most critically, cardiovascular risk reduction. This patient has a very high family history of sudden death, cardiovascular disease, heart attacks, and strokes in multiple first-degree relatives. I’m literally trying to prevent someone from dropping dead.
The insurance company’s response? Denial. But here’s where it gets truly maddening: they denied it without telling us they denied it. They told the patient directly but gave us no notification and no reason for the denial. When we called to find out what happened, they claimed there was no BMI, weight, or height in the submission.
When we looked back, we found that information was clearly documented on each of the three separate times we faxed the paperwork – and we have proof they received it each time. They still denied it.
So we requested an appeal. We’ve been waiting two weeks with no word. My assistant called today to figure out what’s going on, only to discover they now want us to send a secondary appeal by mail, attach the original appeal form with documentation, and send everything through snail mail – it can’t even be faxed, and there’s no digital option. This further delays treatment for a patient whose health is actively deteriorating while we jump through hoops.
The insurance company’s digital shrug translates to “computer says no,” but profits over patients has become their primary goal. Meanwhile, our primary goal is to get the patient better, save healthcare dollars down the road, and prevent someone from dropping dead.
This isn’t just bureaucratic incompetence, it’s a microcosm of the ethical minefield that physicians navigate daily when legal constraints, corporate constraints, and insurance bureaucratic constraints clash with medical necessity. And nowhere is this more apparent than in the wild west of GLP-1 and GLP-1/GIP medications like semaglutide and tirzepatide.
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The Compound Conundrum
Remember October 2024? That’s when the first wave of lawsuits hit, demanding that compounding pharmacies stop producing these medications because the “shortage was resolved.” I actually did a tirzepatide TikTok that month – the first time I went viral. That’s how hungry people are for this information and for the medication. Pun fully intended.
Then came April or May 2025, with another legal broadside targeting semaglutide (Wegovy/Ozempic) compounding specifically. The legal logic seemed straightforward: no shortage means no compounding.
But here’s where legal ethics and medical reality part ways like oil and water.
At the exact moment compounding was supposed to cease, Eli Lilly wasn’t offering cash-pay options for their 12.5mg and 15mg doses of tirzepatide (Zepbound for OSA and obesity/overweight with BMI 27+ with comorbidities, or Mounjaro for type 2 diabetes only). They didn’t even make it available in vials. They literally just made these available this past week. Meanwhile, pharmacies like CVS have cut their agreements and don’t even want to carry these medications anymore. The power that these manufacturers are getting is increased while access is further decreased. PBMs are taking control of everything.
So riddle me this: if there’s no supply available for purchase, how exactly is there no shortage? It’s like declaring there’s no food shortage while keeping the grocery stores locked.
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The Economics of Access
Let’s talk about the elephant in the room: cost. When a month’s supply of brand-name tirzepatide costs more than a person’s rent or mortgage, we’re not just dealing with a pharmaceutical shortage; we’re dealing with an economic accessibility crisis. Which still means no access to me. If patients can’t afford their medications, the practical effect is identical to a shortage: they don’t get treated. It might as well be that the shelves are empty and we’re playing with monopoly paper money.
We’re living in economically uncertain times. Tariffs loom, supply chains remain fragile, and healthcare costs continue their relentless climb. The recent legislation has cut Medicaid funding, further restricting access for vulnerable populations. Meanwhile, pharmaceutical companies play musical chairs with their pricing strategies and availability, leaving physicians to navigate an ever-changing maze of rules and restrictions.
Kaiser further has its own establishment of what it needs for its own criterion, which changes sometimes, and it’s a BMI of 40, not 30. Which is not equal to the medical indication for these medications—it’s their corporate indication for medication. So Kaiser patients are at an even bigger loss.
The Medication Revolution We’re Missing
Here’s what makes this situation particularly maddening: tirzepatide isn’t just another weight loss drug. We know the primary indication is heart attack and stroke prevention, and diabetes treatment. Zepbound is the first medication approved for obstructive sleep apnea. We are primarily seeing improvements in heart attack, stroke, diabetes, cardiovascular disease, and even risk reduction of certain obesity-related cancers. We’re seeing secondary potential improvements in substance abuse, hormone levels, and energy.
Yet we’re letting legal technicalities and insurance bureaucracy stand between patients and what might be the most powerful therapeutic tool we’ve seen in decades.
When a month’s supply of brand-name tirzepatide costs more than a person’s rent or mortgage, we’re not just dealing with a pharmaceutical shortage; we’re dealing with an economic accessibility crisis.
Sulagna Misra MD BCMAS
When a month’s supply of brand-name tirzepatide costs more than a person’s rent or mortgage, we’re not just dealing with a pharmaceutical shortage; we’re dealing with an economic accessibility crisis.
doctorsonsocialmedia.com
The Prescription Tango
As if the access issues weren’t enough, pharmaceutical companies keep changing the rules mid-game. Eli Lilly has been particularly notorious for this, constantly updating dosing guidelines, indications, and availability without clear communication to prescribers. Novo Nordisk with Wegovy has been somewhat more stable, but the information landscape changes so rapidly that keeping up feels like trying to hit a moving target in a hurricane.
How can we provide optimal patient care when we’re constantly playing catch-up with manufacturer decisions? It’s like trying to perform surgery while someone keeps rearranging the operating room.
The Ethical Crossroads
So here we stand at the crossroads of medical ethics and legal compliance. On one side, we have patients who need medication to prevent serious morbidity and mortality. On the other side, we have legal constraints that may prevent us from providing that care through compounding when brand-name options are inaccessible or unaffordable.
The Hippocratic Oath doesn’t say “First, do no harm unless it’s legally complicated.” It says “First, do no harm.” Period. When access to care is denied, when prior authorizations are rejected without cause, when medications are priced out of reach, the ethical physician must ask: what is the right thing to do?
Medical ethics tells us to save lives. Legal ethics tells us to follow the rules. But what happens when following the rules means watching patients deteriorate or die? Medical ethics seems to be an ongoing theme right now, especially within our current political and societal crisis. With Medicaid cuts, people are finding themselves on one side or the other of the political spectrum when healthcare really should be apolitical.
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The Path Forward
I would argue that when faced with this impossible choice, medical ethics must take precedence. If compounding provides access to life-saving medication when corporate gatekeepers fail, then compounding becomes not just an option but an ethical imperative. And it should be up to the doctor to decide if the compounding place is safe or not. That is our job.
Initially, there were definitely bad players taking advantage of people, charging ridiculous amounts like $800 an injection. That is the equivalent of rent—that’s rent for a family of 5 or 10, arguably, depending on where you live. And food and utilities.
But there are also great compounding players, and we have been compounding for eons. That pink bubblegum amoxicillin antibiotic that many kids who weren’t penicillin allergic took as children? That is compounded. Certain medications get compounded regularly because we need different absorptive states for different patients. So compounding is not new, nor is it a dirty word. Why are we treating it like a dirty word?
These medications need to be made in a sterile way, and there are certain places that can legally make these medications. Why are we not allowing them to make them? Would we rather watch our patients die when we know we can potentially intervene because we’ve seen these medications work for a year or two with great outcomes? And now because of bureaucracy, they’re taken away, and we’re all left scrambling to pick up the pieces.
The Bottom Line
The question isn’t whether to compound or not to compound. The question is whether we’re going to let legal technicalities and corporate greed prevent us from saving lives. As physicians, our primary ethical obligation is to our patients, not to pharmaceutical companies or insurance bureaucrats.
When the system fails our patients, we must be willing to work around it—and that’s the entire premise of direct primary care. The direct primary care revolution and movement started because the system was failing, and the doctors who saw cracks in the system left the system so they could provide optimal care for their patients. Arguably, leaving the insurance system and leaving the corporate medical system is in line with the DPC ethics and code of ethics.
When legal constraints conflict with medical necessity, we must choose medicine. When profits are put over patients, we must choose patients.
Because at the end of the day, we became doctors to heal people, not to use AI to fight the denial that was denied by the AI in the first place on a paper that was never read initially. We didn’t sign up for that. I didn’t sign up to be an AI authority. I signed up to be a body detective—a doctor.
The patient with the family history of sudden death from myocardial infarction deserves better than a system that values legal compliance over life-saving treatment. They deserve a physician who will fight for them, even when the fight gets complicated.
That’s not just good medicine. That’s the right thing to do, and it’s a life-saving thing to do.
