Pharmaceutical patient assistance programs — looking for input

HPLC_Greg said:

NauseaFreeNow said: ...regarding the discontinuation data for cost and coverage...

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.

NauseaFreeNow 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…

Financial impact of cost and coverage weight loss beyond medication cost:

• Groceries: SAVED $208/month (eating less)
• Restaurants: SAVED $198/month (fewer meals out)
• Alcohol: SAVED $148/month (stopped drinking)
• Life insurance: Premium REDUCED by $38/month (lower BMI)
• Copays: SAVED $58/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.

Dr.AddMedPHL said:

The affordability discussion here usually stops at individual tactics.

Insurance update relevant to cost and coverage: I just got my prior auth approved through Blue Cross after 3 attempts.

What finally worked: a letter from my endocrinologist documenting BMI history (>3 years), failed diet attempts, comorbidities (sleep apnea + prediabetes), 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.

Following on from CryptoCarl — and this may be the naive question:

Did your prescriber agree with that reading, and if not what was their objection?

Reporting back.

Update: approved on the third attempt after a peer-to-peer. Nothing about my case changed; only who was doing the talking.