Greetings, valued readers! Thanks for stopping by. Today, I cover the continuing saga of EnGuide and my favorite two customer service agents in India, along with a visit with the Notorious Dr. DeLorean for some hand/wrist pain, and just because he deserves to see me at least every couple of months so I can get my money’s worth.
EnGuide Lightning Strikes Twice
There’s no shortage of hell in this purgatory, but this week’s circle belongs entirely to Poona, Yanna, and the rest of the Hyderabad Henchfolk running the frontlines of EnGuide Pharmacy. For my explanation of the who, what, where and why of EnGuide, the GLP-1 specialty arm of Evernorth, which owns Express Scripts and which itself is owned by CIGNA, see my Week 57 Mounjaro Update: A Ride on the Escalator with Poona.
It’s Not about the Money, Right?
Now, you might think that once a pharmacy takes your money—even a meager $67 co-pay—they’d feel some moral or logistical obligation to deliver the medication. Especially since, at the time of the charge, I was down to one injector, with a vacation looming and a cold chain clock ticking. But this is EnGuide we’re talking about, the PBM world’s answer to the DMV, if the DMV also outsourced its help desk to Hyderabad and shipped you thousand-dollar steaks in Styrofoam boxes.
Let me further thicken the plot: this wasn’t just any refill. This was the refill that pushed me over Medicare’s $2,000 out-of-pocket cap for the year, as mandated by the comically named Inflation Reduction Act. Meaning? The next three-month shipment will cost me exactly zero dollars. Zero. Zilch. The big goose egg. Which makes me wonder: is there a subtle incentive for EnGuide to slow-roll the current delivery and push the next one out of 2025 entirely? Could be paranoia. But in the world of PBMs, paranoia is just due diligence.
Liar, Liar, Pants on Fire!
So, I called last Monday. Told Yanna—Poona’s understudy in the Hyderabad Hotline Chorus—that I was leaving on August 4. A lie, yes, but a strategic one. I actually leave on August 10. But I’ve danced this bureaucratic ballet before, and I wasn’t about to trust the EnGuide shipment roulette to align with my real-life calendar. Yanna, ever polite, promised to “escalate” the matter. Which, I believe, involves her forwarding a Post-it note to a supervisor who’s currently out to lunch until Q4.
She also asked if I had enough medicine. Like a fool, I told the truth: one injector left, to be used Sunday. After that, nothing. In hindsight, I should have said I was out and already jonesing for recombinant sustenance in a puddle of post-prandial despair. But I played it straight, and now I’m stuck in tracking-number limbo.
Same Old Song
Note that today is August 4, the shipping date promised by EnGuide. Last night, I received a text message from EnGuide: “EnGuide Pharmacy/CHD: There’s a shipping delay on the order you placed on 07/27 for Rx MO***. It should arrive within 7 business days and we’ll let you know when it ships. Contact us if you’re concerned about running out.”
Once again, I called. This time, I spoke with Angel, the heavenly pseudonym adopted by my latest helpful Indian customer service surrogate. She assured me that the order was already packaged, was just awaiting pickup by the carrier, and would arrive within five days. I reiterated that I was leaving town, now truthfully stating the date as August 10, and asked if she could guarantee that I will receive the Mounjaro by then. She repeated the mantra that it would arrive within five days. I said, “If that means business days, I’m screwed!” She stated that it was calendar days, still cutting it pretty close. I beat the dead horse to a bloody pulp with her, ultimately accepting her assurance that it would take five days—if the carrier picks it up.
So yes, I’m irked. But at least I have a little agency—I can stretch the truth, lift some iron, and vent in long-form prose. Not everyone has that luxury. Which brings me to this week’s case study in pharmacological purgatory…
Meanwhile, in the Outer Rings of EnGuardia…
Let me now share the tale of a fellow traveler through this pharmacological purgatory. I received an email from a reader, a longtime tirzepatide user whose experience with EnGuide makes my shipping delay look like a minor nuisance at the Chick-fil-A drive-thru. For the sake of privacy, we’ll call her Patient X. (Not to be confused with “Drug X,” “Plan B,” or “Subject Y Was Found Unresponsive.”)
Patient X had been taking Mounjaro for three years. Not as part of some TikTok weight-loss fad, but because her lipidologist prescribed it as a preventive intervention. Why? Family history of Type 2 diabetes, weight issues, and—here’s the kicker—she’s also on Repatha for a blocked left anterior descending artery (LAD) supplying blood to her heart. That’s the widowmaker, folks. Real serious cardiovascular stuff.
Enter, the Gatekeeper
But then EnGuide entered stage left, shortly after the transition from Express Scripts to the newly formed, dedicated GLP-1 RA distribution channel on June 15, wielding the flaming sword of prior authorization righteousness. Their first decree? Cancel her prescription. Why? Because she failed to prove she was a “certified diabetic“.
Let that soak in for a second.
This isn’t a nightclub with a velvet rope and a clipboard. There is no card-carrying diabetic club you get into with an HbA1c over 6.5%. But EnGuide demanded precisely that: two consecutive months of high A1Cs as “evidence.” Never mind the fact that her lipidologist—an actual, practicing physician who presumably didn’t get his M.D. from the back of a cereal box—prescribed the drug. EnGuide’s box-checking algorithms weren’t satisfied.
So what did they do? Kicked her off Mounjaro and offered her the same damn drug—tirzepatide—repackaged as Zepbound and approved by the FDA for weight loss instead of Type 2 diabetes. Furthermore, EnGuide would only supply her Zepbound at the starter dose.
Wait, weight loss? Patient X’s doctor—for heaven’s sake—didn’t want her to lose weight. He wanted metabolic stability. You know, that old-fashioned notion of using a drug for a medical reason, not just to please the formulary goblins.
Back to Square One
So she missed a dose. Then another. And now she’s back to square one on the titration ladder. It’ll take six months for her to get back to the therapeutic level she was already tolerating just fine. All because someone or some AI at EnGuide apparently thinks “Zepbound” and “Mounjaro” are as different as Xanax and Xfinity.
Sidebar: Certified Diabetic — The New Elite Status You Didn’t Ask For
Want to keep your medication? Better hope your glucose is high enough!
— Two months of A1C ? 6.5%
— Doctor’s note (optional)
— Bonus points if you have neuropathy, nephropathy, or a limb in a Ziploc bag
Disqualifiers:
— Controlled blood sugar
— Preventive care
— Medical logic
Coming soon: “Prediabetic? Pre-denied!”
Logistics? Who knows!
Patient X lives in a rural area with delivery reliability somewhere between a broken drone and the Pony Express. Sometimes UPS drops packages 450 feet from her door—at the mailbox—no door knock, no notification. Now imagine your Zepbound starter pack roasting in a foam box on the side of the road while your dog barks at squirrels and your pancreas wonders what it did to deserve this.
She’s back on the drug. She’s stabilized, for now. But she’s worried. Not just about her own treatment—but about the broader collapse of sanity in the prescription management industry. EnGuide’s own site boasts they serve 1 in 3 Americans. And that might be the most chilling statistic in this whole fiasco.
A Visit with Dr. DeLorean
Well, folks, you gotta keep a high-priced concierge doc on his toes. You can’t let him think that he can slide by with a $3,500 per year retainer for three 45-minute visits. Especially for an old fart like me, I’m paying the big bucks for some active healthcare management. So, when something hurts, I’m going to see the vaunted internist and deliver my complaint. Sometimes, I deliver my diagnosis and my prescription, but I often display mock deference, just for effect. I scheduled an appontment for today.
My hands and wrists have been painful, and the weird thing is that the onset was relatively sudden and bilateral. Osteoarthritis (OA) is rarely that symmetrical, so I took the coordinated onset seriously, as possible sign of something more serious (as if OA is not serious enough). So, I am clueless, but a good thing I have noted is that I can lift heavy weights during my workout routine, after which my wrists feel better, not worse. This, coupled with the nightly exacerbation (and daily remission) suggests OA to me. Maybe it is just a coincidence that both sides exhibited the same symptoms simultaneously.
In addition to the wrist problem, I’m addressing several other issues. First, I want to keep DeLorean thinking about my functional iron deficiency unti it is resolved to my satisfaction (or until I am enlightened as to why it cannot). I want an explanation about the elevated B-12 from my last blood workup—weirdly out of range on the high side. I’ll update him on the left quadriceps tendon tear, which I am pursuing independently with the orthopedists and physical therapists (as if he gives a rat’s ass). Finally, I want him to titrate my blood pressure medicine (losartan) down to the minimum dose and discuss potential deprescribing.
Purgatory Indeed, with Thanks to EnGuide
And so we drift deeper into this purgatory—where branded biologics play identity games, where bureaucrats demand proof of disease lest you be deemed unworthy of your salvation, and where escalations vanish like whispers into the ether. If this is the future of chronic disease management, then we are not patients—we are pilgrims, stumbling up Dante’s spiral, clutching cold packs and prior authorizations, praying that the algorithms deem us sick enough to treat. Poona may smile, Yanna may escalate, but the path forward feels less like care and more like performance art on a collapsing stage. Welcome to the sacred pharmacy of suffering, where redemption ships “around August 4.”
I’ve tossed enough word salad for today. Not wanting to stray far from the Princesses of Hyderabad theme was a struggle, though. So much else going on here medically. Thing is, I’ll be leaving town for a couple weeks starting Sunday—no lie, Poona! So, instead of leaving you, my dear readers, hanging for a fortnight, I’ll put out another issue of Peptide Purgatory this week with tales of Medicare abuse, disappointment with Dr. Sporty McNeedle (after the big build-up I gave her last week), and of course, the outcome of my visit with the Notorious Dr. DeLorean. Look for it on Wednesday.
Where am I going? My annual ham radio event, this year in Guthrie, Oklahoma. So, I’m escaping the Florida heat for the steamy plains of the Sooner State. Some day, I’ll tell you about the time I was admonished by an Indian department chair, a Brahmin, for using the word “soonest”. I should have asked Angel, “When’s the soonest I will see my shipment.” She would then need to learn this word.
What the hell am I talking about? God only knows.
For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.
