HSA/FSA eligibility for GLP-1 medications — January 2024

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.

Dr.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:

1. Prior authorization appeal with peer-to-peer review
2. Manufacturer copay card (for commercial insurance)
3. Patient assistance programs (Novo Nordisk, Eli Lilly)
4. Compounded medication from a 503B pharmacy ($116/month)
5. 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.