Welcome to the ongoing chronicle of my Type 2 diabetes treatment with the GLP-1 receptor agonist drug Mounjaro. While tracking my progress is pretty boring at this point, I like to pepper my personal stew with current news about GLP-1 RAs. I also share my experiences navigating our flawed healthcare system, a source of chronic frustration all my dear readers have experienced.

To recap my progress, at age 78 I have reduced my HbA1c to 5.3% and lost seventy pounds of blubber in just over one year on Mounjaro. Concomitantly, I’ve amped up my exercise program, particularly in strength building workouts, and I carefully watch my diet. I’ve adopted a low-carb/high protein, now with increased daily caloric intake approach to maintain my current weight. My aim is to maintain these for life, even after I ditch the Mounjaro, which I hope I can do before the end of this year.

I’ll start with this morning’s PBM frustration. My Mounjaro shipment was delayed, so I got on the phone with my supplier’s customer service in India. My experience with the polite purveyor of the corporate credo follows.

EnGuide Me, O Thou Great Algorithm (Part II: Now With Fewer Expectations)

Back in Week 55, I voiced concern that Express Scripts’ decision to offload my Mounjaro prescription to a mysterious new entity called EnGuide might lead to chaos. “They claim this will improve things,” I wrote. “We’ll see.” Well folks, we’ve seen.

After the transfer supposedly occurred on June 15, I placed my usual refill order around June 23, right on schedule. What followed was two weeks of staring at the Express Scripts app, which assured me my order was “PROCESSING.” Not “Shipped.” Not “Delayed.” Just stuck in digital purgatory, like a soul waiting for tech support from Saint Peter’s call center.

Then came the text message—like a kiss-off from a ghosted Tinder date—saying the order was delayed and that it might arrive within seven business days of whenever they eventually ship it. You know, sometime between now and the collapse of Western civilization. Which is helpful, since I had just used my last dose.

“I am not bamboozling you, Sir.”

Naturally, I followed their suggestion to call if I had “any problems.” (Spoiler: I had one.) After battling their outsourced voice assistant—who I think was trained using transcripts from prank calls—I finally reached a real person. Let’s call her “Poona,” since I didn’t catch the actual name and EnGuide isn’t big on transparency.

Poona informed me that my order was… wait for it… delayed. Upon further questioning, she admitted they didn’t even receive the prescription from Express Scripts until June 29. That’s a full two weeks after the alleged transition. So the system that had claimed to be “processing” my order was in fact a Potemkin interface clicking along with all the sincerity of a Hallmark card printed in a war zone.

When I pressed for an explanation, Poona said the transfer had created some “technical hiccups.” That’s one way to describe catastrophic backend dysfunction. She then offered to connect me with one of their pharmacists to discuss my dosage—as if that would produce medication out of thin air. I declined, explaining that my doctor manages my dosing, and what I actually needed was a box with a tracking number on it.

We Suggest You Use a Local Pharmacy

That’s when Poona helpfully suggested I get a fill at a local pharmacy. Right. Because nothing screams efficient care like rewriting prescriptions mid-cycle to accommodate your tech fail. I reminded her that they are, in fact, my mail-order pharmacy—and that their job, shockingly, is to mail the order.

She promised to escalate my case and assured me that I’d probably get it this week. Because nothing builds trust like conditional delivery of essential medication.

I asked about my next refill, since I’ll be traveling in August and prefer not to be held hostage by supply chain roulette. She said I can reorder on July 20, but Dr. DeLorean will need to send a fresh script. I’ve put in that request, fully aware that the odds of a smooth transaction are on par with winning Powerball while being hit by a meteor.

The Bottomless Line

And then Poona gave me the real punchline: she assured me that the rough patch of this transition is now behind us and that “things will go more smoothly in the future.” Will they, Poona? Will they really? Or will my next refill involve a customer service scavenger hunt through three continents and a warehouse run by Rube Goldberg?

Place your bets.

“Alexa, Fix My A1c”

Ladies and gentlemen, in the latest episode of Your Tax Dollars at Work, a team of researchers in South Korea has discovered that talking to a smart speaker—yes, that Alexa you’ve been yelling at for years—can actually improve blood sugar and reduce depression in older adults with Type 2 diabetes.

This is not a joke. Well, not entirely.

In a randomized clinical trial, participants over 60 were given voice-activated speakers programmed with diabetes self-care prompts. These weren’t just fancy kitchen timers or music players—no, they were equipped to spew out diabetes education modules, daily self-monitoring reminders, and affirmations like, “You’ve got this, even if your pancreas doesn’t.”

“Alexa, Fix My Brain”

Over six months, the folks who interacted with these peppy plastic sugar-coaches saw improvements in both HbA1c and mental health scores. The control group, who got standard care without the dulcet tones of their new AI friend, didn’t do quite as well.

The researchers speculate that the speaker worked as a “digital companion,” improving routine and mood. In other words, Alexa became the nagging spouse some of us never had, or maybe already have. One that doesn’t forget anniversaries, misplace the car keys, or tell you, “You don’t need to check your sugar right now—you just had a cookie!”

Now, before you rush to Best Buy to get your very own glycemic echo chamber, let’s be clear: the study was small, short-term, and limited to participants who were willing and able to learn how to use the device. So if you routinely yell “HELLO COMPUTER” like Scotty in Star Trek IV, this might not be your jam.

The Future is Now

Still, it raises some interesting possibilities. Could Alexa one day administer your insulin, reorder your Mounjaro from EnGuide (insert sarcasm here), or offer real-time shaming when you reach for the Ben & Jerry’s?

Imagine:

“Alexa, what’s my glucose level?”
“Judging by that donut you just inhaled, I’d say… high.”

“Alexa, what’s the weather?”
“Clear skies. A perfect day for a walk. Just saying.”

We’re living in strange times, folks. If someone had told me a decade ago that managing diabetes would involve injecting $1,000 hormones and chatting with a hockey puck on the kitchen counter, I’d have asked what they were smoking—and whether it was covered by Medicare.

But here we are. Stay tuned. Siri might be next.

My Mounjaro Week by the Numbers

• Weight: 173.8 lbs — steady as she goes.
• Fasting Glucose: 100 mg/dL — down from 106.
• Stelo Overall Average: 106 mg/dL — about the same.

Humans Optional

So this week, I was guided—misguided, perhaps—by Poona, the outsourced oracle of EnGuide, and soothed by the dulcet tones of Alexa, my imaginary pancreas whisperer. One delivered a placebo of platitudes while failing to deliver actual medicine. The other delivered imaginary empathy while pretending to be helpful.

It’s clear the future of diabetes care is here: voice-activated robots and labyrinthine mail-order supply chains. One tells you your order is delayed because your order is delayed. The other tells you to breathe deeply and visualize an HbA1c of 6.5%.

At this point, I can’t decide who’s more reassuring: Poona with her escalations and probable shipments, or Alexa with her sugar-shaming weather reports.

Either way, we’re all just one software update away from being told:
“We care deeply about your health. Now please hold.”

For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.

Greetings and welcome to the continuing chronicles of this geriatric wunderkind’s travails treating his Type 2 diabetes with Mounjaro. Here, laced with my firsthand experiences, I give you the sweet lowdown on diabetes drugs, their weight loss cousins, and the healthcare industry. My opinions are — well, you know what they say about opinions.

For the uninitiated, Mounjaro is one of a class of incretin drugs called GLP-1 receptor agonists that started out as diabetes treatment but later became the darlings of the weight loss industry. Once studies and anecdotal experiences established the weight loss possibilities of GLP-1 RAs, drug manufacturers quickly obtained approval to ply their wares to the weight loss community. Mounjaro (generic: tirzepatide) was relabeled as Zepbound, Ozempic (semaglutide) became Wegovy, and Victoza (liraglutide) became Saxenda.

GLP-1 RAs have benefited many people, but in their euphoria, proponents, particularly in the weight loss industry, tend to downplay their risks. The prospect of easy, painless, automatic weight loss is too big a carrot not to take down in one big gulp. Unfortunately, unless accompanied by stringent dietary and strength training, that weight loss will be partially lean tissue — muscle. And, let’s face it— if people have failed at dieting and exercise programs in the past, they are seeking weight loss without the necessary demanding work.

That leads into this week’s two stories. One is about yet another expensive complimentary drug to stem the muscle loss associated with GLP-1 RA weight loss, a potentially costly boon for those looking for miracles. The other is a sell-out to Big Pharma by doctors who prefer drugs over lifestyle modifications as front-line treatment for obesity. Behold, a two-way winning week for Big Pharma!

The Two-Edged Syringe: Saving Muscle, Selling Out

Your weekly purveyor of metabolic mayhem returns with a double shot of GLP-1-related developments—one that might actually help people keep muscle while losing weight, and another that suggests the American College of Cardiology has finally been fully absorbed by the Big Pharma Borg.

Let’s start with the encouraging news. A recent phase 2 study suggests that semaglutide, when paired with the biologic bimagrumab, can preserve lean muscle mass during weight loss. That’s right: you get the fat loss benefits of a GLP-1 agonist without your thighs disappearing faster than a 401(k) in a bear market. In the trial, the combination led to a 15.6% reduction in body fat but actually increased lean mass by 1.5%. Compare that to semaglutide alone, which dropped fat by 8.6% but took 4.9% of muscle with it—like tossing out the baby with the bathwater, if the baby were your quadriceps.

Now, before we pop the champagne and start pricing out new belt sizes, there’s a big pharma-sized catch: cost. Bimagrumab is a monoclonal antibody, which means it doesn’t come cheap. Think “second mortgage” tier, not “skip Starbucks” tier. It’s also still experimental, so you won’t be getting this dynamic duo at your local CVS any time soon—unless your insurance plan has recently adopted a policy of underwriting miracles.

Snatching Victory from the Jaws of Defeat (with drugs)

While one hand gives (maybe), the other hand takes. Or in this case, shovels. This week, the American College of Cardiology issued new guidance that would allow physicians to initiate pharmacologic therapy for obesity without requiring patients to fail lifestyle interventions first. On the surface, this seems compassionate—why wait for people to suffer the futile shame spiral of diet failure when we have effective medications?

Yet scratch that surface and you hit gold—gold coins, that is. The ACC’s endorsement reads less like clinical guidance and more like a press release jointly issued by Eli Lilly and Novo Nordisk. By removing the need for a lifestyle “try-and-fail” period, they effectively convert every overweight adult into a potential subscriber to a lifelong, extremely expensive prescription plan. It’s a win for stockholders, not necessarily for patients—or for society, which now must reconcile the idea of drug-first treatment for a condition that remains deeply behavioral and environmental.

Let’s Fudge a Diagnosis

But the guidance doesn’t stop at endorsing first-line pharmacotherapy. It also tiptoes up to a truly uncomfortable ethical line. The document suggests that when insurance balks at covering GLP-1s for “just obesity,” clinicians might consider whether a diagnosis of prediabetes or type 2 diabetes could be used to meet coverage requirements. In plain English: if the BMI won’t get your patient the drug, go fishing for a glucose-related diagnosis code that will.

This kind of chart-padding may be common in modern medicine, but let’s not pretend it’s benign. It risks turning real diseases like Type 2 diabetes into mere leverage for insurance billing—a perversion of clinical diagnosis into a transactional code game. It also muddies the waters for those of us who have diabetes, who already navigate enough bureaucratic skepticism about whether we “really need” these drugs.

If Big Pharma’s marketing department had slipped this into a slide deck at a sales meeting, we’d all roll our eyes. That it comes from the American College of Cardiology in a formal position document should provoke outrage.

The Bottom Line

So what’s the net effect? You can preserve muscle now—maybe—if you can afford a biotech-grade add-on. And if you’re a doc, you no longer must waste time advising diet and exercise before hitting the GLP-1 easy button. It’s all very convenient. For everyone except the patient paying $1,200 a month for the privilege of being slightly less obese, with slightly less muscle.

I’ve spent 56 weeks harping on the dangers of muscle loss during GLP-1-mediated weight loss. This bimagrumab news is a legitimate scientific advance. But the rush to put everyone on injectables—without even a speed bump labeled “behavioral change”—feels like a cynical shortcut. It’s hard to view it as anything but a declaration of defeat on the lifestyle front. Or maybe just a good quarter for Novo.

My Week on Mounjaro

I continued physical therapy for my “good” knee. Monday’s session was a “come to Jesus” conference with the therapist, where I reviewed the treatment plan, noting several aspects she was failing to provide. So, naturally, my second visit that week was a torture session. Be careful what you ask for!

The only other medical encounter during the week was an always pleasant visit to my podiatrist. She runs a small, family practice, a legacy of her dad, who is a respected, semi-retired podiatrist in this area. Many of the other podiatric practices have been swallowed up in the great private equity healthcare consolidation, which drives a wedge between patients and physicians, so it is refreshing to find a friendly practice where patients are treated like family.

But I digress. Let’s move on to the numbers for the week.

• Weight: 173.6 lbs — down 2.6 lbs.
• Fasting Glucose: 106 mg/dL — about the same.
• Stelo Overall Average: 105 mg/dL — down slightly.

See You Next Week

That’s all for this week from your favorite Type 2 cyborg. Muscle matters. Ethics matter. And if the ACC needs help rewriting their next press release, I hear Novo’s hiring.

See you next week—syringe in hand, dumbbells at the ready, and moral compass (mostly) intact.

For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.

I’m back with the latest installment of my Mounjaro-fueled foray into Type 2 diabetes control. At age 78, I’ve now spent over a year jabbing myself with my preferred GLP-1 receptor agonist, watching my HbA1c drop into smugly normal territory, trimming my pharmaceutical roster, and saying goodbye to seventy-five pounds of metabolic avoirdupois.

These weekly updates serve two purposes: to share my personal progress and to vent — with style — about the medical-industrial comedy that surrounds drugs like Mounjaro. For those of you starting out with GLP-1 therapy, I offer this mix of anecdote and invective as a cautionary tale. Yes, these drugs are powerful tools. No, they are not magic. Without commitment, effort, and at least a little dietary sanity, the only thing they’ll reliably shrink is your wallet.

My Appetite is Back

Let’s talk about the so-called “miracle” of appetite suppression. The YouTube pharmababblers — pumped full of sponsorships and pseudoscience — treat GLP-1s like Ozempic Fairy Dust. But I can tell you from experience: unless you plan to dose-chase into orbit, the effect fades. Mine lasted just long enough to rewire my eating habits toward low-carb territory, which suits me fine now that I’m focusing more on muscle than weight loss. I’m at the 7.5 mg dose, with no plans to go higher. Appetite suppression? Who needs it, already? Glycemic control is the goal — not accidental anorexia.

Mounjaro Ain’t Cheap!

Sticker shock alert: if your insurance doesn’t cover GLP-1s, you’re staring down $1,200 a month. Even with Medicare Part D and a drug plan, I’m shelling out $250/month for my Mounjaro fix. It’s enough to make you consider robbing a CVS — though ironically, they’d probably deny the claim. And now the insurers are finding new and exciting ways to “manage utilization,” which brings us to this week’s delightful screed.

The PBM Shuffle: EnGuide and the Great GLP-1 Shell Game

If you’re using GLP-1s to keep your beta cells from waving the white flag, congratulations — you’ve just been volunteered into a high-stakes farce run by Pharmacy Benefit Managers (PBMs). Think of it as “Squid Game,” but for your pancreas.

EnGuide: The New Dog in Express Scripts’ Kennel

As of June 15, Express Scripts has outsourced your Mounjaro refills to a startup called EnGuide Pharmacy — “powered by CHD,” which they swear stands for Certified Health Delivery and not Congestive Heart Disease, though I remain unconvinced. The rebrand promises “convenient home delivery,” which in PBM-speak means “we’re adding another layer of bureaucratic fog between you and your meds.”

Let’s call EnGuide what it is: a utilization management checkpoint, a rebate harvester in a lab coat, a denial machine with lipstick. You don’t need a pharmacy — you need a permission slip.

The Pre-Authorization Gauntlet

If your GLP-1 refills are starting to feel like Kafkaesque quests, that’s because they are. These so-called “designated pharmacies” specialize in exhausting you into compliance — or better yet, giving up. The only weight they help you lose is the crushing burden of hope.

CVS Joins the Party

Never one to miss a chance to profit, CVS Caremark has instituted its own “clinically aligned” GLP-1 centers. Think automated chatbots with lab coats and PowerPoint slides. You may be denied medication not because you’re noncompliant, but because you’ve lost “too much” weight. Yes, being too healthy is now a problem — just not for your insurer’s earnings report.

Walgreens? They’ve launched “Health Corner,” which is like telemedicine, except it’s run by people who used to work the cosmetics counter.

The Real Agenda

Please note that a subset of patients taking a GLP-1 for weight loss will need to be enrolled and engaged in a lifestyle modification program before receiving the medication. This requirement is chosen by your employer or health plan. You will be notified if you are in this program and advised what to do when you place your medication order.

—Evernorth Health Services

These PBM spinoffs aren’t here to help you — they’re here to reshape the narrative. Their goals are simple:

• Control cost (their cost, your health be damned)
• Harvest data (ever hesitate before hitting ‘Refill’? That’s logged)
• Steer behavior (click here to confirm you’re not abusing this miracle drug)

And if you want to keep using your preferred pharmacy? Sorry, that ship has been rerouted — probably to a container port in Shenzhen. You’ll need your doctor to fax a 27-page form to EnGuide’s secret lair while standing on one leg reciting the Hippocratic Oath.

Sidebar

What’s happening?

PBMs (Pharmacy Benefit Managers) like Express Scripts, CVS Caremark, and OptumRx are increasingly pushing GLP-1 prescriptions through designated specialty pharmacies — such as Evernorth EnGuide Pharmacy, a subsidiary of Cigna/Express Scripts. They claim it’s for “convenience.” It’s really about control.
What is a ‘designated pharmacy’?
It’s a locked gate disguised as a red carpet. You may still “choose” another in-network pharmacy, but that requires effort, paperwork, and frequently — your doctor’s direct involvement. For many, it’s easier to comply than to fight.
Why now?
GLP-1s like Mounjaro and Wegovy are expensive and wildly popular. PBMs want to curb usage, maximize rebates, and closely monitor patient adherence. Routing scripts through their own subsidiaries gives them tighter reins — and a bigger piece of the financial pie.
What changes for you?
You might need new prior authorizations.
You may face refill delays.
You’ll be nudged toward online portals, virtual “coaching,” and data-sharing “opt-ins.”
You’ll lose flexibility in choosing how and where your medications are dispensed.
Is this legal?
Yes. Is it patient-centered? Not even close. It’s a quiet recalibration of access, placing corporate interests over medical autonomy.
What can you do?
Keep accurate records of delays and denials.
Talk to your doctor about keeping a paper prescription on file.
Escalate unresolved access issues to your state insurance commissioner or attorney general.
Push back. The more noise patients make, the harder it becomes for these silent maneuvers to stay hidden.

Who Wins?

Not you. Not your doctor. Not even your long-suffering pancreas.

The big winners are:

• Evernorth/EnGuide, now raking in profits from “specialty care” and shadow rebates.
• Cigna, CVS, UnitedHealth, who’ve built vertical empires where denial is a service.
• Wall Street, who loves nothing more than “patient channeling” and “therapeutic rationalization” — euphemisms for “we made it so annoying they quit.”

What Can You Do?

Short of chaining yourself to the EnGuide loading dock, consider the following:

• Refill early and often.
• Get a paper script to take elsewhere.
• Alert your doctor when “transition of care” gets mentioned — it’s rarely a good thing.
• Document every delay, denial, and duck-and-cover — they may come in handy with your state board or Medicare appeal.

And above all: remember, GLP-1s may suppress your appetite — but nothing suppresses a PBM’s appetite for profit.

This Week on Mounjaro

I placed my first order with EnGuide. No glitches yet — but I’ll be watching. Probably harder than they’re watching me.

The medical carousel slowed this week: just one PT session and a Tuesday visit with Dr. DeLorean to review my recent CT scan. No tumors — hooray! But my iron levels still look anemic and hemoglobin is slightly low. He’s not worried. I am. So I’m watching this like a hawk — or, more appropriately, like a turkey guarding his giblets.

The Mounjaro Numbers

• Weight: 176.2 lbs — steady as she goes.
• Fasting Glucose: 107 mg/dL — a modest drop.
• Stelo Overall Average: 107 mg/dL — also down a notch.

Conclusion: Same Mounjaro, New Tricks, More Nonsense

This week’s lesson? The battle for better health doesn’t end at the injection site. GLP-1s might lower your glucose, but they won’t protect you from PBMs weaponizing “care coordination” against your sanity. As for me, I’ll keep taking the drug, watching the numbers, and telling the truth — because someone has to.

See you next week, unless I’ve been put on hold indefinitely by a robot named “Clara” at EnGuide.

For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.