Putting this up for argument rather than for agreement. I have read it twice and I am still not certain what it supports.
Denials are usually procedural rather than clinical, and the order that works reflects that. Get the denial reason in writing, because it names the criterion you failed. Then supply the documentation that criterion asks for — usually documented BMI with a comorbidity, or a failed prior therapy. Then appeal, and ask for a peer-to-peer review, because a prescriber talking to a reviewing clinician resolves a large fraction of denials that written appeals do not. Manufacturer copay assistance is separate and applies mainly to commercial insurance, and patient assistance programmes are means-tested rather than a discount.
Where I think it is weakest: the comparator does most of the work in how this gets reported, and it is not the comparator most people think they are citing.
What I am trying to establish is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. I have searched first, so if this is covered somewhere point me at it and I will read it.
Figures above are from the primary publication rather than the press summary. If a number here disagrees with one you have, post yours and we will work out which of us is reading a secondary source.
fiona_glasgow said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Insurance update relevant to cost and coverage: I just got my prior auth approved through Anthem after 4 attempts.
What finally worked: a letter from my endocrinologist documenting BMI history (>3 years), failed diet attempts, comorbidities (NAFLD + metabolic syndrome), and referencing the SURMOUNT trial data.
If your PA keeps getting denied, don't give up. Request a peer-to-peer review between your doctor and the insurance medical director. That's what finally broke through for me.
fiona_glasgow said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Filing a mild objection. Mild because I might be wrong; an objection because nobody has addressed the case that does not fit. The affordability discussion here usually stops at individual tactics. At list price this class is out of reach for most of the people who would benefit, and no amount of appeal strategy changes that — it is a pricing problem wearing a paperwork costume.
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View ResultsDr.CardioMD said:The affordability discussion here usually stops at individual tactics.
Insurance coverage hack for cost and coverage: if your insurance denies brand Wegovy/Ozempic, consider these alternatives:
- Prior authorization appeal with peer-to-peer review
- Manufacturer copay card (for commercial insurance)
- Patient assistance programs (Novo Nordisk, Eli Lilly)
- Compounded medication from a 503B pharmacy ($116/month)
- Canadian pharmacy (requires prescription, ~40-60% savings)
Don't let cost prevent access to effective treatment. There are options at every price point.
BenResearch_OR said:Insurance update relevant to cost and coverage: I just got my prior auth approved through Anthem after 4 attempts.
Same pattern here, and in the same order. I had assumed I was the exception until I read this.