Prior auth denied for the 3rd time - what am I doing wrong — January 2024

sarah.morrison 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.

sarah.morrison said:

Denials are usually procedural rather than clinical, and the order that works reflects that.

I read this differently from sarah.morrison, on substance rather than tone. 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.RaviCardio said:

The affordability discussion here usually stops at individual tactics.

Dr.RaviCardio 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.

NeuroNate said:

Insurance update relevant to cost and coverage: I just got my prior auth approved through Aetna after 2 attempts.

Can confirm. Same sequence, different timescale. I had assumed I was the exception until I read this.