Prior auth denied for the 3rd time - what am I doing wrong — my results so far

PharmD_Rodriguez 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…

PharmD_Rodriguez said:

...regarding the discontinuation data for cost and coverage...

I want to reframe the discontinuation narrative. We don't say "insulin fails because blood sugar rises when you stop it." We don't say "antihypertensives fail because BP goes up without them."

Why do we apply different logic to anti-obesity medications? The answer is stigma. We still, unconsciously, believe obesity is about willpower rather than biology. The discontinuation data actually PROVES it's a chronic biological condition requiring ongoing treatment.

This reframing isn't semantic — it has implications for insurance coverage, treatment duration, and patient expectations.

Dr.ObesityMed said:

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

Dr.ObesityMed said:

...my insurance denied cost and coverage coverage because...

Insurance denial is the single biggest barrier to GLP-1 access. Let me share the appeal framework that worked for me and several community members:

1. Document medical necessity (BMI, comorbidities, failed alternatives)
2. Reference clinical practice guidelines (AGA, AACE, Endocrine Society)
3. Cite cost-effectiveness data (preventing diabetes/surgery saves money long-term)
4. Request peer-to-peer review between your doctor and the plan's medical director
5. File external appeal with your state insurance department if internal appeal fails

Don't accept the first denial. The appeal process exists for a reason.

PharmD_Rodriguez 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…

Second this. The detail I would add is minor and it is already implied above.

From the other side of the consultation, briefly.

Insurance update relevant to cost and coverage: I just got my prior auth approved through UnitedHealthcare 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 SELECT 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.