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.
The bit I cannot resolve on my own is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. I would rather have one careful answer than five confident ones.
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.
sarah.morrison 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 Aetna after 2 attempts.
What finally worked: a letter from my endocrinologist documenting BMI history (>3 years), failed diet attempts, comorbidities (T2DM + hypertension), and referencing the STEP 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.
sarah.morrison said:Denials are usually procedural rather than clinical, and the order that works reflects that.
I read this differently from sarah.morrison, on substance rather than tone. 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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Shop Reference StandardsDr.RaviCardio said:The affordability discussion here usually stops at individual tactics.
Dr.RaviCardio said:...compounded vs brand cost and coverage...
This debate comes up weekly and I think both sides have valid points:
Pro-brand: FDA-approved, manufacturing standards guaranteed, clinical trial data directly applicable
Pro-compounded: 10x cost savings, same active molecule, independent testing available, accessibility
My position: if you can afford brand or have insurance coverage, that's the gold standard. If not, properly tested compounded from a 503B pharmacy is a reasonable alternative. Neither side should shame the other.
NeuroNate said:Insurance update relevant to cost and coverage: I just got my prior auth approved through Aetna after 2 attempts.
Can confirm. Same sequence, different timescale. I had assumed I was the exception until I read this.