GLP1 Prescriptions

Can GLP1 medicines be prescribed through this service? Yes!

Follow up visits are required every 3 months to comply with state regulations. You must have a follow up visit every 3 months to obtain refills. The visit cost is the same as the published visit fee listed on the home page of SelfPayMD.com, no subscriptions, no surprise fees.
What you need to start: basic background medical information as described below, then make an appointment here: https://michaelgray.clientsecure.me/contact-widget

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The “Fine Print” and Commonly Asked Questions

We will walk through all of the requirements during the visit itself but the summary below covers most of the questions you will be asked as well as some general information on GLP1s.

Q: What does the medical visit fee cover? A: Evaluation for medical appropriateness, screening for contraindications, advice for side effects or dosing adjustments that are needed. Lab fees are not included. Medicine costs are not included.

Q: Do you prescribe compounded GLP1s? A: No, we cannot offer this due to insurance and regulatory considerations. Only brand name prescriptions can be sent.

Q: Do I have to use a specific pharmacy or supplier? A: No! We can send prescriptions to any pharmacy of your choosing. It is recommended that you shop around for the best pricing. I like Lilly Direct for Zepbound because they have a discount program and mail the medicine straight to your home. Wegovy pills can be prescribed via any pharmacy you specify. However, we can use any FDA approved GLP1 you prefer and I recommend you check with the manufacturers websites for discount programs if you are self pay. Many offer substantial savings.

Q: Do I have to get labwork prior to using a GLP1? A: Generally yes, labs are needed to ensure patient safety and for regulatory compliance. You can forward test results yourself or report them at the time of visit-- We need AST, ALT, BUN, creatinine, TSH and the date they were done. You may have already had these labs done through your primary care or from a prior emergency room visit or from a life insurance physical. If you do not have any lab results available we can supply a generic lab sheet to get the labs drawn at a lab of your choosing such as Quest or LabCorp. Last I checked Quest will do these labs for under $100 but again, shopping around is best.

Q: Which is better, oral or injectable GLP1? A: To a large extent this is personal preference. The shots are absorbed more readily compared to the oral so the weight loss tends to be more pronounced. Side effects might be a little more pronounced too for the same reason. Most of the GLP1 shots are weekly (other than liraglutide/Saxenda which is daily). The oral versions are daily. Oral Wegovy should be taken on an empty stomach each morning with water only, no other medicines or food or supplements. This will help absorption. The pills do not have to be refrigerated while the shots do need refrigeration.

Q: Can I travel with GLP1 shots in view of the need for refrigeration? A: Generally yes, with some precautions. For injections (Wegovy, Ozempic, Mounjaro, Zepbound): These medications should be kept refrigerated as much as possible, but being unrefrigerated for travel is usually ok as long as you keep the following tips in mind.
Pack in a carry-on: Never put your medication in checked luggage, where it can be lost or exposed to extreme temperatures in the cargo hold.
Use a quality cooler: Keep your pens or vials in an insulated bag or medical travel cooler with ice packs to maintain the required temperature (usually 36°F to 46°F or 2°C to 8°C).
Prevent freezing: Do not place medication directly against frozen ice packs, as freezing will ruin the medication.
Understand TSA rules:
Declare meds: When going through airport security, declare your medically necessary liquids and ice packs to a TSA officer.
Ice pack status: Medically necessary ice packs are allowed, even if they are partially melted or slushy. However, ensure they are frozen solid when you first pass through security to avoid questions.
Keep in original packaging: Keep the pens or vials in their original packaging, which has your prescription label on it.
Consider airline policies: Some airlines may store medications in an onboard refrigerator on longer flights, but availability varies.
Even if the cool packs melt you are usually fine for an airline flight as long as the vial has not exceeded 95 degrees or been exposed to heat longer than 4 days. Some sources say semaglutide is shelf stable and can tolerate up to 77 degrees for 15 days without impacting its efficacy. If the product has been exposed to these conditions, it should re-stabilize once refrigerated.

If the nature of your trip is prolonged and refrigeration is not possible then it may be best to leave the medicine at home and restart upon return. You can reach out for guidance on this when you get back as the dosing would depend on how many shots were missed and whether you have been experiencing side effects.
If the medicine changes during travel and you see cloudiness, discoloration, floating particles, or crystals then most likely the vial went bad and should be discarded.

Q: How do I find the best price on the medicine itself? A: Lots of exciting things are happening in the GLP1 world of weight loss. Eli Lilly has dropped the price substantially on genuine Zepbound, now starting at $349/month for a starting dose, and rising to $499 at the top dose last I checked. I recommend you shop around, check brick and mortar pharmacy pricing on GoodRx, check Amazon or Mark Cuban pharmacies for home delivery prices, or Lilly Direct for Zepbound. They all have pricing available online. Here are a couple resources:

https://www.novomedlink.com/obesity/products/treatments/wegovy/cost-coverage/wegovy-patient-savings.html#pill

https://www.lilly.com/lillydirect/medicines/zepbound

Q: Is this available in all states via telemedicine? A: Unfortuantely, no. Many states have restrictions and regulations that make telemedicine prescribing of GLP1s impossible or impractical. We strive to remain complaint with all rules and regulations. Last I checked we cannot offer GLP1 prescriptions via telemedicine in LA, MS, AR, AL due to state regulations. VA requires a 1 month check in as well as a home blood pressure cuff. Several states require a full body photograph and/or live video consultation (no phone only visits).
For Pharmacy related issues or to change the pharmacy please message through the patient portal.

Q: Are GLP1s safe in pregnancy? A: Unknown. There has not been enough research on this topic so it is recommended not stop GLP1s at least 2 months prior to conception. For unintended conception it is recommended to immediately stop GLP1s. GLP1s are not recommended while nursing. If female and prescription medicine is desired then using a form of birth control is recommended during the medication use and for 6 months after.

Q: What kind of medical questions will you ask me during the evaluation?

A: We need to know that the medicine is medically appropriate and that there are no contraindications or dangers based on your medical history. I will need to know:
Weight and diet history:
Height:
Maximum weight: lbs bmi (BMI calculator: https://www.nhlbi.nih.gov/calculate-your-bmi )
Current weight: lbs bmi
Patient's desired weight: lbs bmi
Previous diet history (attempts, successes, challenges):
Current diet:
Current physical activity:
Current weight loss medication (if any, if none please indicate): none
Duration of present therapy: n/a
Tolerating well: n/a
Side effects/adverse responses: n/a
Past weight loss medicines that have been used and outcome. This is important if a prior authorization is needed. Must include past weight loss medications taken, reason for stopping, any adverse effects and contraindications to alternative medications:
List any prior weight loss medicines used:
Last visit with PCP/prescribing provider:
Next planned PCP/prescribing provider:
LABS AND MONITORING: (indicate most recent value below, labs should be recent):
AST:
ALT:
BUN:
Creatinine:
TSH:
preventative care review (not related to weight loss but just mentioned as general good medical practice):
immunization recommendations:
tetanus within past 10 years
covid boosters annually or per CDC guidelines
flu shots annually
shingles vaccination x 2 doses recommended at age 50
No anxiety or depressive symptoms, no suicidal or homicidal thoughts (bring this to our attention right away if this affects you)
No concerns about safety at home or at work, domestic violence or otherwise (bring this to our attention right away if this affects you)
colonoscopy recommended starting at age 45 and periodically thereafter depending on the findings
diabetic eye exam not applicable due to status as non diabetic
blood pressure checks annually at minimum, more frequent if abnormal

PMH:
General medical history is needed:

In addition, specifically no contraindications are reported such as:
Patients with active diabetes mellitus should share their medications and program details with their primary treating physician.
Patients currently taking hypoglycemic agents (insulin, biguanides, sulfonylureas, meglitinides, thiazolidinediones, a-glucosidase inhibitors, DPP-4 inhibitors, SGLT-2 inhibitors and bromocriptine) for other conditions should not be given weight loss medication via telemedicine that directly lowers blood sugars (GLP-1 inhibitors, metformin), please see your primary care or endocrinologist for guidance.
gastroparesis
Thyroid cancer
MEN tumors
Patients with a personal or family history of medullary thyroid cancer or Multiple Endocrine Neoplasia syndrome type 2 should not be placed on GLP-1 inhibitors)
Gallbladder disease
Renal disease
Uncontrolled hypertension
Mental health history (eating disorder)
Pregnancy status: n/a and/or not pregnant

Past surgical history:

Medications:

Allergies to medications:

Any significant Family History?
Specifically, no history of multiple endocrine neoplasia/MEN or Thyroid Cancer?

Social history:
Smoker?
No excessive or problematic alcohol use?

Q: Who is a candidate for GLP1 use as far as body weight?

A: National criteria generally agree that
Obesity is defined by a BMI >30
Overweight is defined by a BMI 25-29.9
To qualify for weight loss medications, an individual must either have a BMI over 30 or have a BMI of 27-29.9 AND weight related comorbidities (such as diabetes mellitus, dyslipidemia, hypertension, heart disease, sleep apnea, and symptomatic osteoarthritis). In addition, weight loss medication is only appropriate in patients who have not met weight-loss goals (loss of at least 5% of total body weight at 3-6 months) with comprehensive lifestyle intervention alone.

Q: What side effects can occur with GLP1s? A: The most common side effects of GLP-1 receptor agonists (such as semaglutide/Ozempic/Wegovy, liraglutide/Saxenda/Victoza, tirzepatide/Mounjaro/Zepbound) are:
Very Common: Nausea (most frequent), Vomiting, Diarrhea, Constipation, Loss of appetite, Feeling full quickly, Abdominal discomfort / bloating. --These usually happen when starting or increasing dose and often improve after a few weeks.
Common: Acid reflux / heartburn, Indigestion, Burping, Fatigue, Headache, Dizziness, Injection site redness or irritation
Less Common but Important: Gallstones / gallbladder issues (from rapid weight loss), Dehydration (from vomiting/diarrhea), Low blood sugar (mainly if combined with insulin or sulfonylureas), Delayed stomach emptying (gastroparesis-like symptoms), severe fullness, vomiting undigested food
Rarely reported: pancreatitis, gallbladder disease, renal impairment, suicidal thoughts. If you develop suicidal thoughts or need help please call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor.
Other side effects can occur so reach out if you experience any side effects you are concerned with.
Dehydration can occur so make sure to drink 64-90 oz of water a day (women) and 120+ ounces a day (men).

Q: How do you use the autoinjector pens? A: Check the manufacturer websites for video examples. Here is one for Wegovy:
https://www.wegovy.com/taking-wegovy/how-to-use-the-wegovy-pen.html

Q: Are there other weight loss medicine options if you cannot use a GLP1? A: Yes, there are non GLP1 medicines that can be considered. The Non GLP1 medicines are generally less potent than GLP1s, are prone to various side effects, but are also generic and relatively inexpensive by comparison.
Bupropion:
Bupropion is primarily an antidepressant but has been studied for weight loss. It is also used for anxiety, ADHD and smoking cessation. Bupropion aims to suppress appetite.
Efficacy: Studies have shown modest weight loss benefits. When combined with naltrexone, as in the Contrave formulation, it has shown more significant weight loss benefits.
Average Weight Loss: Approximately 3-5% of initial body weight over 6 to 12 months.
Most Common Side Effects: insomnia, dry mouth, headache, anxiety/jitteriness, nausea (early in treatment), increased sweating

Naltrexone:
Naltrexone is an opioid antagonist. For weight loss, it is often used in combination with bupropion. Naltrexone aims to reduce cravings.
Efficacy: When combined with bupropion (Contrave), it shows more substantial weight loss than either drug alone.
Average Weight Loss: Studies show about 5-9% weight loss of initial body weight over a year with the combination therapy.
Most Common Side Effects: nausea, dizziness, headache, fatigue, anxiety/restlessness, abdominal cramping, diarrhea

Metformin:
Metformin is primarily used to manage type 2 diabetes but is sometimes used off-label for weight loss. Metformin aims to decrease hunger through a couple of mechanisms.
Efficacy: Modest weight loss, especially beneficial for individuals with insulin resistance.
Average Weight Loss: Usually around 2-3% of initial body weight over several months to a year.
Most Common Side Effects: diarrhea, bloating, gas, nausea, metallic taste

Topiramate:
Topiramate is an anticonvulsant that has also been examined for weight loss. Topiramate is used to increase satiety.
Efficacy: Significant weight loss in various studies, more so when combined with another medication like phentermine (Qsymia) which we do not prescribe.
Average Weight Loss: As monotherapy, it can result in a weight loss of about 5-6% of initial body weight over 6 to 12 months. Combined with phentermine, it can lead to higher weight loss, around 9-15%.
Most Common Side Effects: tingling in hands/feet (called paresthesia), mental fog or word-finding difficulty, taste changes (like soda tastes flat), fatigue, dry mouth

Q: Can phentermine or Qsymia be prescribed via telemedicine? A: Unfortunately they cannot. Phentermine and Phentermine-topiramate (Qsymia) are not available in this program because they are DEA controlled substance (CDS) which requires an in-person visit to prescribe.

Q: Why do you send multiple prescriptions to the pharmacy for weight loss? A: All GLP1s are dosed in a ‘titration’ which starts at a low dose and then increases gradually. The purpose of this is to reduce side effects and complications by allowing your system to gradually adjust to the medicine.
For GLP1s I will label the prescriptions Month 1, Month 2 etc. Start with the lowest dose. If the pharmacy will not accept multiple prescriptions as the dose is titrated up then you'll have to make follow up appointments each month or change pharmacies. I usually don't require monthly visits for this purpose though, typically a follow up every 3 months is sufficient. The multiple prescriptions are so you don’t have to make a follow up visit every month. Make sure to have a follow up appointment every 3 months so you don't run short and let it lapse. MEDICINES WILL NOT BE REFILLED BY SECURE MESSAGE, YOU MUST HAVE AN APPOINTMENT. If you receive 4 months of your prescription the month 4 prescription is really intended as a buffer, do not wait till then make an appointment.

Q: Do I need to stop GLP1s prior to surgery? A: Generally yes, especially if you are undergoing general anesthesia. Most guidelines recommend stopping the GLP1 at least a week before surgery but I have seen some surgeons recommend stopping it 2 weeks before so make sure to check with your surgeon on this.

Q: How important is follow up? A: It is critical. We must insist on follow up to be compliant with standard of care and various state medical board requirements.
**IMPORTANT: Follow up visits-- Please schedule a follow up appointment a month BEFORE your prescriptions run out so that we can reassess and/or change the dosing if necessary. Follow up appointments are mandatory as we must document progress and safety. Prescriptions will not be refilled via secure messaging or by calling customer support for this program, they will not be approved.**
-Weight management is an ongoing condition that requires regular follow-up until goal weight loss has been achieved and maintained. Regular check-ins and coordinating programs with nutrition and automated care have been proven to be a formula for achieving one's goals.
- If you are overweight, even a 10 lb weight loss can reduce your risk of diabetes, hypertension, stroke and the need for medication. Every little bit helps!

Q: What else can I do to help achieve my weight loss goals? A:
- A calorie conscious high protein (100g+ per day) diet can help you lose weight.
- Daily mild to moderate exercise like a brisk walk for 30 minutes is important to help keep your metabolism stable.
-Drink enough water
- Get enough sleep

Here are some good tips:
https://medlineplus.gov/ency/patientinstructions/000385.htm

Q: Can you be my primary care provider? A: No. Telemedicine has inherent limitations in terms of what can safely be done so it is best to have a primary care doctor in person locally. If you do not have a primary care doctor please find one at your earliest convenience. Please keep your primary care doctor informed of all medicines you are using, including those prescribed via telemedicine. You can print out the visit notes from the patient portal and share them with your doctor.

Q: What if I have an emergency? A: Secure messaging is not to be used in an emergency as it can take several days for a reply. If you believe you have developed an emergency condition call 911 or proceed to the nearest emergency room.

Q: How is billing accomplished? A: I do not accept any insurance on this site, all visits are self pay. A credit card on file is required to make an appointment but it WILL NOT be charged until you actually have a visit. In the interest of efficiency we require payment at the time of service and will not accommodate requests to bill you later, sorry.

Q: What if I have insurance? A: It is best to seek care through a participating provider within your insurance network to utilize your insurance. We will not submit claims to your insurance company. Also, SelfPayMD is NOT OPEN to anyone with government sponsored health coverage such as Medicare or Medicaid. Federal Law prohibits our business model for anyone with federal coverage so please see an in network provider in person locally if you have Medicare or Medicaid. As mentioned in the Terms Of Service, if you are receiving a discounted self pay price via SelfPayMD.com you are attesting that you cannot afford the full price and that your income is insufficient to otherwise receive care.

Q: What if I have other questions I want to ask before making an appointment to be seen as a patient? A: Log in to SelfPayMD to ask any questions anonymously on the public bulletin board. Using the public bulletin board does not create a doctor patient relationship and is only meant to triage or provide general advice on whether telemedicine is appropriate for your particular concern. To move forward with treatment advice please make an appointment.

Disclaimer: The above is my opinion and my practice style, other doctors may have other guidelines and practices that are either more strict or less strict. Please ask your doctor directly about any specific concerns you have regarding practice mechanics, billing, follow up protocols etc. Right now I am the only doctor on the site but in the future there may be other doctors with other rules and requirements. Thank you for understanding and thank you for reading!

-V/R

Michael Gray MD JD