A reference post rather than a discussion. Corrections are the point; I would rather this be right than mine. It is about cost and coverage, and it is deliberately narrow — everything I am not confident about is marked as such.
What is actually established
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.
The condition it depends on
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 am not sure about
What I am after 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.
InsuranceTom 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.
InsuranceTom said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Pushing back on InsuranceTom 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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Shop Reference Standardsmike_nyc said:The affordability discussion here usually stops at individual tactics.
My insurance denied my PA related to cost and coverage. Has anyone successfully appealed? I'm considering going compounded instead.
RetaRick_CA said:Insurance update relevant to cost and coverage: I just got my prior auth approved through Aetna after 2 attempts.
Same pattern here, and in the same order. Nothing to add that would improve it.