Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the talking.
Reporting this the way I would want to read it: what I did, what it cost, what I can actually verify.
Coverage criteria are plan-specific rather than insurer-specific. Two people with the same insurer and different employers have different rules, which is why "my insurer covers it" is not transferable information.
What I actually want to know is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. Tell me what I have not thought of.
TomTeleRx said:Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the…
TomTeleRx 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.
TomTeleRx said:Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the…
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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Browse GL BiochemDataDave said:The affordability discussion here usually stops at individual tactics.
Financial impact of cost and coverage weight loss beyond medication cost:
- Groceries: SAVED $242/month (eating less)
- Restaurants: SAVED $152/month (fewer meals out)
- Alcohol: SAVED $102/month (stopped drinking)
- Life insurance: Premium REDUCED by $32/month (lower BMI)
- Copays: SAVED $62/month (fewer BP/cholesterol meds)
Net impact after medication cost: approximately BREAKING EVEN. The medication pays for itself through reduced food spending and healthcare costs. This surprised me.
TrialNerd_Beth said:TomTeleRx said: ...compounded vs brand cost and coverage...
Mine went the same way, slower. The detail I would add is minor and it is already implied above.