This gets cited here weekly, usually second-hand, so it is worth setting out what it does and does not establish.
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 subgroup findings are the part I trust least — with enough subgroups something is always significant, and these were not all pre-registered.
What would genuinely help is knowing what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. Happy to be told the question itself is wrong.
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.
Dr.GastroMayo said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Dr.GastroMayo 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.
Dr.GastroMayo said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Pushing back on Dr.GastroMayo here. 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 BiochemDr.BariatricHTX 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 ($100/month)
- Canadian pharmacy (requires prescription, ~40-60% savings)
Don't let cost prevent access to effective treatment. There are options at every price point.
Dr.PainCLE said:Dr.GastroMayo said: ...compounded vs brand cost and coverage...
Second this.