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is semaglutide covered by insurance

Is semaglutide covered by insurance?

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Table of Contents

Introduction

Semaglutide is a medication with significant therapeutic potential, and its accessibility is closely tied to insurance coverage. This article aims to explore the insurance coverage landscape for semaglutide and its implications for patients. By understanding the mechanisms of semaglutide, analyzing insurance coverage options, identifying challenges, and proposing strategies, we can shed light on the importance of insurance coverage and advocate for improved access to this valuable medication.

Understanding Semaglutide

Semaglutide is a pharmaceutical agent known for its therapeutic properties. It exerts its effects by interacting with specific receptors in the body, leading to various physiological responses. The mechanisms of action of semaglutide involve modulating key pathways to achieve the desired therapeutic outcomes. Studies have demonstrated the effectiveness of semaglutide in achieving positive outcomes in patients. The medication provides notable benefits, including improved symptom management, enhanced quality of life, and potential long-term health benefits. Comparing semaglutide with alternative medications reveals its unique features and advantages. Understanding how semaglutide performs in comparison to other treatment options is essential for evaluating its efficacy and safety profiles.

doctor handing a patient a prescription

The Role of Insurance Coverage

Insurance coverage plays a vital role in ensuring patients can access necessary medications. It provides financial support and reduces the economic burden associated with treatment, enabling individuals to receive the care they need without compromising their financial stability. To comprehend the insurance coverage landscape for semaglutide, it is crucial to understand the various types of insurance plans available. These include private insurance, Medicare, and Medicaid, each with its own eligibility criteria, coverage limitations, and cost-sharing arrangements. Several factors influence the extent of insurance coverage for medications like semaglutide. These factors may include formularies, drug tiers, coverage restrictions, and the cost-sharing structure established by insurance providers. A comprehensive understanding of these factors is essential in navigating the insurance coverage landscape.

Insurance Coverage for Semaglutide

An analysis of the current insurance landscape provides valuable insights into the coverage status of semaglutide. By examining trends, policies, and practices, we can gain an understanding of the prevailing coverage scenarios and identify potential areas for improvement. Analysis of Private Insurance Coverage Private insurance coverage for semaglutide varies among providers. An in-depth analysis of private insurance coverage options sheds light on the criteria, copayments, and potential challenges patients may encounter in accessing semaglutide through private insurance plans. Medicare plays a significant role in healthcare coverage for many individuals. Evaluating Medicare coverage policies for semaglutide offers insights into access, cost-sharing arrangements, and potential barriers faced by Medicare beneficiaries seeking this medication. Medicaid, a government-funded program, provides crucial healthcare coverage for low-income individuals. Examining Medicaid coverage for semaglutide reveals eligibility criteria, limitations, and potential differences in coverage between states.

Medicaid coverage for semaglutide can vary depending on the specific state and the patient’s eligibility criteria. Medicaid is a government-funded healthcare program that provides coverage for low-income individuals and families. Each state administers its own Medicaid program, and while there are certain federal guidelines, coverage options and policies can differ. In general, Medicaid programs are designed to cover medically necessary prescription medications. However, coverage for specific medications, including semaglutide, may be subject to certain criteria and restrictions. These criteria may include the patient’s medical condition, treatment guidelines, and formulary considerations.

It is important for individuals seeking Medicaid coverage for semaglutide to consult their state’s Medicaid program or Medicaid Managed Care Organization (MCO) for detailed information on coverage policies. Medicaid beneficiaries can typically access this information through their state’s Medicaid website or by contacting their local Medicaid office. Additionally, healthcare providers and pharmacists can provide guidance on the specific coverage options and requirements for semaglutide under Medicaid in a particular state. They can help navigate the process of obtaining prior authorization if required, submitting necessary documentation, and understanding any cost-sharing obligations. It is worth noting that Medicaid coverage policies and formularies are subject to change, and it is important for individuals to stay informed about updates and any potential modifications to coverage criteria. In summary, Medicaid coverage for semaglutide may be available, but it is contingent upon the specific guidelines and policies of each state’s Medicaid program. Individuals should consult their state’s Medicaid program, Medicaid Managed Care Organization, or healthcare providers for accurate and up-to-date information regarding Medicaid coverage for semaglutide.

Challenges and Limitations of Insurance Coverage

Semaglutide’s cost can be a barrier to access for many patients. High medication costs and copayments can create financial strain, making it difficult for individuals to afford and adhere to their prescribed treatment. Prior authorization requirements and their impact on access prior authorization is a common requirement imposed by insurance providers. The process of obtaining prior authorization for semaglutide can lead to delays in access, administrative burdens for healthcare providers, and potential frustration for patients seeking timely treatment.

Insurance coverage for semaglutide can vary depending on the specific insurance plan and provider. Semaglutide is a prescription medication used for the treatment of certain medical conditions, such as diabetes. The coverage for semaglutide is typically determined by the insurance company’s drug formulary, which is a list of medications covered by the plan. Private Insurance: Private insurance plans, such as those offered through employers or purchased individually, may provide coverage for semaglutide. However, the extent of coverage can vary. Some insurance plans may cover semaglutide as a preferred or tiered medication, while others may require prior authorization or have certain limitations on coverage. It is important for individuals to review their insurance plan documents, including the formulary and any associated coverage policies, to determine if semaglutide is covered and under what conditions. Additionally, reaching out to the insurance company’s customer service or speaking with a healthcare provider can provide further clarification on coverage details.

Coverage Restrictions and Limitations

Coverage Restrictions and Limitations Insurance providers may impose coverage restrictions and limitations on medications like semaglutide. These restrictions can include step therapy protocols, quantity limits, or preferred drug lists, which may hinder patient access to semaglutide and limit treatment options.

Typical insurance coverage restrictions for semaglutide can vary depending on the specific insurance plan and provider. However, some common coverage restrictions that may apply to semaglutide include:

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    1. Prior Authorization: Insurance plans may require prior authorization before they will cover semaglutide. Prior authorization involves obtaining approval from the insurance company, usually based on specific criteria or guidelines before the medication can be prescribed and covered.

    2. Step Therapy: Step therapy is a coverage restriction that requires patients to try and fail other medications before semaglutide will be covered. Insurance plans may require patients to first attempt and demonstrate inadequate response to less expensive or preferred medications before providing coverage for semaglutide.

    3. Quantity Limits: Insurance plans may impose quantity limits on semaglutide, limiting the amount of medication that can be prescribed within a specific time period. This restriction ensures that patients are using the medication as intended and prevents excessive or unnecessary use.

    4. Preferred Drug Lists: Some insurance plans have preferred drug lists, also known as formularies, which are lists of medications that are covered at a lower cost or with fewer restrictions. If semaglutide is not included in the preferred drug list, it may have higher copayments or require additional steps for coverage.

    5. Cost-Sharing: Insurance plans often involve cost-sharing, where patients are responsible for paying a portion of the medication cost out-of-pocket. This can be in the form of copayments, coinsurance, or deductibles. The specific cost-sharing requirements for semaglutide will depend on the insurance plan and the individual’s coverage details.

It’s important to note that these coverage restrictions can vary widely among different insurance plans and providers. Some insurance plans may have more lenient coverage policies for semaglutide, while others may have stricter requirements. It is advisable for individuals to review their insurance plan documents, including the formulary and coverage policies, to understand the specific coverage restrictions that apply to semaglutide under their plan. Additionally, healthcare providers and pharmacists can provide valuable guidance on navigating insurance coverage restrictions, assisting patients in obtaining prior authorization, and exploring potential alternatives or appeals if coverage restrictions pose challenges to accessing semaglutide.

Health insurance form in man hand

Strategies to Navigate Insurance Coverage

Navigating insurance coverage for semaglutide can be complex, but there are several strategies that can help individuals maximize their coverage and improve access to this medication. Here are some effective strategies to consider:

  • Review Insurance Plan Documents: Carefully review your insurance plan documents, including the formulary and coverage policies. Understand the specific coverage details for semaglutide, such as copayments, prior authorization requirements, and any coverage limitations or restrictions.
  • Consult with Healthcare Provider: Engage in open communication with your healthcare provider. They can provide valuable guidance on insurance coverage for semaglutide, help navigate the process, and assist with any necessary documentation or prior authorization requests.
  • Prior Authorization Assistance: If prior authorization is required, work closely with your healthcare provider’s office to gather and submit all necessary information to the insurance company. Ensure that medical records, documentation of failed alternative therapies (if applicable), and any supporting evidence are provided to support the need for semaglutide.
  • Appeal Denied Claims: If your insurance claim for semaglutide is denied, consider appealing the decision. Insurance companies may have an appeals process in place. Work with your healthcare provider to gather relevant medical information and submit a formal appeal, emphasizing the medical necessity and effectiveness of semaglutide for your condition.
  • Explore Patient Assistance Programs: Investigate patient assistance programs offered by the manufacturer of semaglutide. These programs can provide financial assistance or even free or discounted medication to eligible individuals who meet specific criteria. Check the manufacturer’s website or contact them directly to inquire about available programs.
  • Utilize Prescription Savings Cards: Look for prescription savings cards or discount programs that may help reduce the out-of-pocket cost of semaglutide. These programs, often available through various organizations or online platforms, can provide savings on prescription medications, including semaglutide.
  • Research State Pharmaceutical Assistance Programs: Some states have pharmaceutical assistance programs that can help individuals with medication costs. Research if your state offers such programs and determine if semaglutide is covered or eligible for assistance.
  • Stay Informed: Keep yourself informed about updates and changes to your insurance plan’s coverage policies. Formulary changes, coverage criteria revisions, and new programs may affect coverage for semaglutide. Regularly check for updates from your insurance company and stay in touch with your healthcare provider.
  • Seek Insurance Expertise: Consider consulting an insurance expert, such as an insurance broker or patient advocate, who can provide guidance on navigating insurance coverage, understanding policy details, and identifying alternative coverage options if necessary.
  • Document and Keep Records: Maintain a record of all communication, including phone calls, emails, and letters, related to insurance coverage for semaglutide. This documentation can be valuable in case of disputes, appeals, or future reference.

Remember, each insurance plan may have different coverage policies and requirements for semaglutide. It’s important to understand your specific plan’s guidelines and work closely with your healthcare provider to navigate insurance coverage successfully.

Impact of Insurance Coverage on Patients

The impact of semaglutide insurance coverage on patients is significant and can have both positive and negative effects on their access to and management of the medication. Here are some key impacts to consider:

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    1. Affordability: Insurance coverage plays a crucial role in making semaglutide affordable for patients. With coverage, patients typically have a lower out-of-pocket cost, such as copayments or coinsurance, which reduces the financial burden associated with the medication. Affordable access to semaglutide enables patients to adhere to their prescribed treatment regimen without incurring excessive costs.

    2. Treatment Adherence: Adequate insurance coverage for semaglutide can improve treatment adherence among patients. When the medication is more affordable and accessible, patients are more likely to consistently take their prescribed doses, follow the recommended treatment plan, and maintain better glycemic control. Improved adherence contributes to better overall health outcomes and reduces the risk of complications associated with diabetes.

    3. Health Outcomes: Insurance coverage for semaglutide has the potential to positively impact patients’ health outcomes. Semaglutide is known for its effectiveness in managing blood sugar levels, promoting weight loss, and reducing the risk of cardiovascular events. When patients have access to semaglutide through insurance coverage, they are more likely to experience improved glycemic control, weight management, and a reduced risk of diabetes-related complications.

    4. Quality of Life: Insurance coverage for semaglutide can significantly enhance the quality of life for individuals with diabetes. The medication’s positive impact on glycemic control, weight management, and overall well-being can lead to improved energy levels, reduced fatigue, and better mental and emotional health. Patients may experience a greater sense of control over their condition and an improved ability to participate in daily activities and engage in a fulfilling life.

    5. Access to Necessary Medication: Without insurance coverage, the cost of semaglutide may be prohibitively high for many patients. Lack of coverage can create barriers to accessing the medication, leading to potential delays or even complete inability to obtain semaglutide. In such cases, individuals may be forced to make difficult choices between their financial stability and their health.

    6. Health Disparities: Insurance coverage for semaglutide can help reduce health disparities among individuals with diabetes. Access to affordable medication through insurance coverage ensures that individuals from diverse socioeconomic backgrounds have equal opportunities to manage their condition effectively. It helps bridge the gap between those who can afford the medication and those who cannot, promoting equitable healthcare access.

    7. Stress and Emotional Well-being: The availability of insurance coverage for semaglutide can alleviate stress and anxiety related to the financial burden of managing diabetes. When patients have coverage, they experience peace of mind, knowing that they can access the medication they need to effectively manage their condition. This can contribute to improved emotional well-being and reduced psychological distress associated with the financial aspect of healthcare.

Policy Implications and Future Outlook

Policy implications and the future outlook for semaglutide are significant areas of consideration to enhance access and ensure optimal use of this medication. Here are some key policy implications and future perspectives:

Coverage Expansion: Policymakers should prioritize expanding insurance coverage for semaglutide to ensure that more individuals with diabetes have access to this effective medication. This can involve advocating for inclusion of semaglutide in formularies, reducing copayments, and minimizing coverage restrictions. Expanding coverage can help improve health outcomes and reduce the financial burden on patients.

Formulary Considerations: Insurance formularies play a crucial role in determining which medications are covered and at what cost. Policymakers and insurance providers should consider including semaglutide as a preferred or Tier 1 medication within formularies, as appropriate. This would ensure easier access and lower cost-sharing for patients, encouraging its use as a first-line treatment option.

Prior Authorization Streamlining: Streamlining the prior authorization process for semaglutide can help expedite access to the medication. Policymakers can work with insurance companies to simplify and standardize the process, reducing administrative burdens for healthcare providers and ensuring timely approval for patients who meet the appropriate criteria.

Cost Reduction Strategies: Policymakers and healthcare stakeholders should explore strategies to reduce the cost of semaglutide, making it more affordable for patients. This can include negotiating pricing agreements with pharmaceutical manufacturers, promoting alternatives when available, or implementing cost-sharing assistance programs to alleviate the financial burden on patients.

Value-Based Pricing: Considering value-based pricing models for semaglutide can incentivize its use and ensure appropriate reimbursement based on its clinical effectiveness and health outcomes. Such pricing models can be designed to reward positive patient outcomes and encourage the use of medications like semaglutide that have demonstrated significant benefits.

Patient Education and Support: Policymakers should invest in initiatives to improve patient education and support regarding semaglutide. This can include providing resources, information, and counseling to patients and healthcare providers to ensure appropriate and optimal use of the medication. Emphasizing the benefits of semaglutide and its role in diabetes management can help improve patient adherence and overall treatment outcomes.

Research and Development: Continued research and development efforts in the field of diabetes management are essential to advance the understanding and efficacy of semaglutide. Policymakers can support funding for research studies, clinical trials, and real-world evidence generation to expand the evidence base and provide a stronger foundation for policy decisions.

Collaborative Efforts: Policymakers, healthcare providers, insurance companies, patient advocacy groups, and pharmaceutical manufacturers should collaborate to address the challenges associated with semaglutide access and coverage. This collaboration can involve regular communication, sharing of best practices, and joint advocacy efforts to improve policies and regulations surrounding semaglutide and diabetes management.

In the future, there is potential for increased utilization of semaglutide as its benefits become more widely recognized. Advances in technology and the development of more convenient administration methods, such as once-weekly injectable formulations, may enhance patient adherence and simplify treatment. Additionally, ongoing research and innovation in the field of diabetes management may lead to the development of new and improved medications that complement or enhance the efficacy of semaglutide.

Shortage of Semaglutide

The availability of branded semaglutide products has been a topic of concern in recent years, with reports of shortages affecting patient access to this vital medication. These shortages can arise due to various factors, such as production issues, supply chain disruptions, or increased demand. As a result, individuals who rely on semaglutide may face challenges in obtaining the branded medication through traditional channels.

In response to the shortage of branded semaglutide products, consideration has been given to the use of compounded versions of the medication. Compounding pharmacies are specialized facilities that can create customized medications by combining individual ingredients according to a specific prescription. While compounding has long been used to meet unique patient needs, it is important to approach compounded medications with caution and thorough evaluation.

Compounded versions of semaglutide can offer a potential solution to address the shortage of branded products, as they can provide patients with access to the active pharmaceutical ingredient (API) necessary for treatment. Compounding pharmacies have the ability to source the API and prepare the medication in a formulation that aligns with the patient’s needs. This allows for a tailored approach in dosage strength, formulation type (such as injectables or oral solutions), and potentially mitigates the impact of supply chain disruptions.

However, it is crucial to recognize that there are certain considerations and potential limitations associated with compounded versions of semaglutide. Firstly, the quality and consistency of compounded medications may vary, as they are not subject to the same stringent regulations and quality control standards as commercially manufactured pharmaceutical products. It is essential to work with reputable and accredited compounding pharmacies to ensure the safety and efficacy of the compounded semaglutide.

Secondly, the availability of the API for compounding purposes should be carefully monitored. In times of a branded product shortage, the availability of semaglutide’s API may also be affected, making it challenging for compounding pharmacies to consistently provide the medication. This highlights the need for proactive communication between healthcare providers, patients, and compounding pharmacies to ensure a steady supply and address any potential issues related to availability.

Additionally, the cost of compounded semaglutide should be taken into consideration. Compounded medications may not be covered by insurance plans, leading to potential financial implications for patients. It is crucial for patients to explore the cost implications, potential reimbursement options, and discuss these factors with their healthcare provider and insurance company.

Furthermore, the decision to utilize compounded semaglutide should be made in consultation with healthcare professionals who have expertise in diabetes management. They can evaluate the patient’s specific needs, consider the risks and benefits of compounded medications, and guide the patient in making an informed decision.

While compounded semaglutide may serve as a temporary solution during shortages, efforts should continue to address the root causes of branded product shortages. Collaboration between pharmaceutical manufacturers, regulatory bodies, and healthcare stakeholders is essential to ensure an uninterrupted supply of semaglutide to meet patient needs.

The shortage of branded semaglutide products has raised concerns about patient access to this critical medication. Compounded versions of semaglutide offer a potential alternative to mitigate the impact of shortages and provide patients with access to the active pharmaceutical ingredient. However, caution should be exercised, and careful consideration given to the quality, availability, and cost implications of compounded medications. Efforts should continue to address branded product shortages and ensure a consistent supply of semaglutide to meet the needs of individuals with diabetes. By maintaining open lines of communication between healthcare providers, patients, and compounding pharmacies, we can work towards ensuring accessible and reliable options for semaglutide treatment, regardless of supply chain challenges.

Conclusion

In conclusion, insurance coverage plays a crucial role in ensuring patient access to semaglutide, a highly effective medication. By understanding semaglutide’s mechanisms, analyzing insurance coverage options, addressing challenges, and proposing strategies, we can promote the importance of comprehensive coverage for semaglutide and advocate for policies that enhance accessibility. However, it’s important to acknowledge that insurance coverage may not always be sufficient or accessible for all individuals. In such cases, private pay programs like BmiDoctors.com have emerged as valuable alternatives that make semaglutide more affordable and accessible to patients.

Private pay programs, such as BmiDoctors.com, offer innovative solutions to address the financial burden associated with semaglutide. These programs provide discounted pricing, patient assistance, and other cost-saving options that can significantly reduce the out-of-pocket expenses for individuals. By leveraging bulk purchasing power and negotiated agreements with pharmaceutical companies, private pay programs strive to make medications more affordable for those who may not have adequate insurance coverage or face high copayments.

One notable advantage of private pay programs like BmiDoctors.com is the convenience and accessibility they offer to patients. Through online platforms and streamlined processes, individuals can easily navigate the program, enroll, and receive their medications promptly. This eliminates potential delays or administrative hurdles often associated with insurance coverage and prior authorization requirements.

Moreover, private pay programs can bridge the gap for individuals who fall into specific coverage scenarios. These programs may cater to patients who are uninsured, underinsured, or have insurance plans that do not adequately cover the cost of semaglutide. By providing alternative avenues for accessing semaglutide at reduced costs, private pay programs contribute to improved medication adherence, better disease management, and enhanced overall health outcomes.

While private pay programs offer viable options, it’s important to consider their limitations. Not all patients may be eligible or financially able to participate in such programs. Additionally, the sustainability and availability of private pay programs may vary, and their coverage options may not be as comprehensive as traditional insurance plans.

Looking ahead, it is crucial to advocate for policies that promote affordable and accessible insurance coverage for semaglutide. This includes addressing the barriers faced by individuals without insurance or those who encounter high copayments and coverage restrictions. Collaborative efforts between insurance providers, pharmaceutical companies, healthcare providers, and advocacy organizations are essential to create a healthcare system that ensures equitable access to semaglutide for all patients in need.

In conclusion, while insurance coverage remains a key determinant of access to semaglutide, private pay programs like BmiDoctors.com have emerged as valuable alternatives, making this medication more affordable and accessible to individuals who face financial challenges. By combining efforts to improve insurance coverage and supporting innovative private pay programs, we can strive towards a future where semaglutide is readily available to all patients, regardless of their insurance status or financial circumstances. Through comprehensive coverage options and alternative affordability programs, we can ensure that semaglutide continues to transform the lives of individuals with diabetes, empowering them to effectively manage their condition and improve their overall well-being.

BMI Doctors is a private pay program and we do not accept any insurance. See our semaglutide pricing page for details on our weight loss program!

Research Citations

Here are some relevant references that discuss insurance coverage and access to medications:

  1. Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. JAMA. 2007;298(1):61-69. doi:10.1001/jama.298.1.61
  2. Chambers JD, Loomer S, Huo H, Zallman L, Sommers BD. Changes in health care use and costs after Medicaid expansion: a mixed-methods study. Ann Intern Med. 2019;171(2):96-104. doi:10.7326/M18-1980
  3. Cummings JR, Lavarreda SA, Rice T, Brown ER. The effects of varying periods of uninsurance on children’s access to health care. Pediatrics. 2009;123(3):e411-e418. doi:10.1542/peds.2008-2372
  4. Zgibor JC, Songer TJ. External barriers to diabetes care: addressing personal and health systems issues. Diabetes Spectrum. 2001;14(1):23-28. doi:10.2337/diaspect.14.1.23
  5. Solberg LI, Desai JR, O’Connor PJ, Bishop DB, Devlin HM. Diabetic patients who smoke: are they different?. Ann Fam Med. 2004;2(1):26-32. doi:10.1370/afm.20
  6. Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med. 2004;351(6):575-584. doi:10.1056/NEJMsa040609

These references provide insights into healthcare access, utilization, and the impact of insurance coverage on medication use. While they may not specifically address semaglutide, they offer a broader understanding of the complexities surrounding insurance coverage for prescription medications. It’s important for individuals to check with their insurance provider or pharmacist regarding coverage details for semaglutide and other medications.

Questions and Answers: Is Semaglutide covered by insurance? 

The insurance coverage for Semaglutide varies. It is essential to check with your specific insurance provider to determine if it is covered under your plan.

The list price of Wegovy® is around $1,350 for a 28-day supply before insurance. The cash price can be higher, averaging around $1,988.22.

The Affordable Care Act does not require health plans to cover obesity-related medications or surgeries. Coverage depends on the specific plan and prescription benefits.

Coverage for Wegovy® under commercial or private insurance, including employer-covered plans, varies. It is recommended to speak with a benefits advisor at your company to determine coverage specifics.

Generally, Medicare does not cover medications for overweight or obesity, including Wegovy®. Medicaid coverage for such medications varies by state and is rarely provided. Coverage by Tricare also varies.

Uninsured individuals typically have to pay the full cash price for Wegovy®, as patient assistance programs may not be available for this medication.

Ozempic® is often covered by most Medicare and other insurance plans, but pharmacy coupons or cash prices might help reduce the cost.

Coverage for Ozempic® by insurance plans, including Medicare, for weight loss purposes may depend on the specific plan and the condition it is being prescribed for.

Ozempic® is usually covered by most insurance plans, including Medicare. Pharmacy coupons or cash prices may assist in managing the cost.

Dr. Jay Flottman

Dr. Jay Flottmann is a physician in Panama City, FL. He received his medical degree from University of Texas Medical Branch and has been in practice 21 years. He is experienced in military medicine, an FAA medical examiner, human performance expert, and fighter pilot.
Professionally, I am a medical doctor (M.D. from the University of Texas Medical Branch at Galveston), a fighter pilot (United States Air Force trained – F-15C/F-22/AT-38C), and entrepreneur.

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