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ForumsInternationalHas anyone dealt with german private insurance (pkv) vs statutory (gkv)?

Has anyone dealt with german private insurance (pkv) vs statutory (gkv)?

B12Beth Wed, Apr 16, 2025 at 1:17 AM 36 replies 1,942 viewsPage 1 of 8
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B12Beth
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Apr 16, 2025 at 1:17 AM#1

Posting this because the summary going around does not say what the paper says, and the difference matters for how people here are using it.

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.

Where I think it is weakest: the comparator does most of the work in how this gets reported, and it is not the comparator most people think they are citing.

What I am trying to establish is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. Not looking for reassurance. Looking for the part I have got wrong.

Note on sourcing:
Figures above are from the primary publication rather than the press summary. If a number here disagrees with one you have, post yours and we will work out which of us is reading a secondary source.
13 8GraceAZ_72, carl_compliance, DanielChem_CHI and 10 others
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FDA_TrackerJim
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Apr 16, 2025 at 2:11 AM#2
B12Beth said:
Denials are usually procedural rather than clinical, and the order that works reflects that.

Telehealth prescriber review for cost and coverage: I've used 4 different telehealth platforms to get my GLP-1 prescription. Comparison:

FeaturePlatform APlatform BPlatform C
Initial Consult$53$93$0
Monthly Follow-up$43Included$53
Prescription SpeedSame day24-48 hoursSame day
Lab MonitoringRequiredOptionalRequired

I settled on the one that required labs — it shows they care about safety, not just prescribing volume.

Last edited: Apr 16, 2025 at 5:11 AM
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PharmacoVig_BOS
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Apr 16, 2025 at 3:05 AM#3
B12Beth said:
Denials are usually procedural rather than clinical, and the order that works reflects that.

I read this differently from B12Beth, 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.

11 6DataDave, Dr.GutHealth, amsterdam_pete and 8 others
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sean_dublin
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Apr 16, 2025 at 3:59 AM#4
PharmacoVig_BOS said:
The affordability discussion here usually stops at individual tactics.
PharmacoVig_BOS 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.

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MASHdoc_SA
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Apr 16, 2025 at 9:08 AM#5
FDA_TrackerJim said:
Telehealth prescriber review for cost and coverage: I've used 4 different telehealth platforms to get my GLP-1 prescription.

Mine went the same way, slower. I had assumed I was the exception until I read this.

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