Doctor won’t write appeals. Changed insurance and was denied GLP1 coverage (even thought i was already on it)

[Anonymous]

Been on it since May, switched insurance and denied during prior authorization.

Now the doctors office says they don’t do appeals…so it’s on me?

Wegovy IS covered…it was just denied because it wasn’t making progress? But I’m not at maintenance dose. I’ve lost 15 pounds.

What are my options:
Use an online doctor who might be savvy at getting approvals (Midi)
Appeal myself?
…something else?

I am really disheartened at the denial AND lack of help.

[Anonymous]

Just go online and get a prescription! I took a picture of myself and filled out a form and got a prescription. First 3 months $350 and then it’s $100-200 a month after (depending on dose). Just go around your doctor.

[Anonymous]

I’ve worked in appeals for a decade. You are entitled to do an appeal as the member.

It is crappy that your doctor won’t do an appeal.

Have you not lost 5% of your body weight?

Get your medical records from your doctor from about 6 months since before you started the GLP-1. Write a letter outlining your weight loss efforts/failure pre GLP-1. Note date of starting and height/weight/BMI.

Note an exercise plan (even just walking) note a diet/nutrition plan that you are doing concurrently with GLP-1. Doesn’t have to be complicated. No dessert, no soda, focus on protein and vegetables.

Note your current height/weight/BMI and percentage of body weight loss along with with dose you were on and the plan (continuing to titrate up to highest dose, etc)

Good luck. There are timelines from the date of the denial so read the denial letter carefully and get the info sent in quickly.

[Anonymous]

Anonymous wrote:Just go online and get a prescription! I took a picture of myself and filled out a form and got a prescription. First 3 months $350 and then it’s $100-200 a month after (depending on dose). Just go around your doctor.

How?

[Anonymous]

Anonymous wrote:

Anonymous wrote:Just go online and get a prescription! I took a picture of myself and filled out a form and got a prescription. First 3 months $350 and then it’s $100-200 a month after (depending on dose). Just go around your doctor.

How?

Don’t do this. You’ll be getting a compounded version with God knows what in it.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Just go online and get a prescription! I took a picture of myself and filled out a form and got a prescription. First 3 months $350 and then it’s $100-200 a month after (depending on dose). Just go around your doctor.

How?

Don’t do this. You’ll be getting a compounded version with God knows what in it.

That has worked for many of us.

Google it op. Brello, lavender, hers, etc

[Anonymous]

If you haven't lost the amount of weight that insurance requires you to lose, then they aren't going to cover it. It's unclear from your post if that's what's going on.

[Anonymous]

Anonymous wrote:If you haven't lost the amount of weight that insurance requires you to lose, then they aren't going to cover it. It's unclear from your post if that's what's going on.

I’m not on the maintenance side yet. I’ve lost 4%.

[Anonymous]

Call the insurance company. Their default is no. Argue a bit. Mention this was prescribed by the doctor, and denying coverage opens them up to law suits. I wish that approach didn't work, but it does.

[Anonymous]

My insurance denied coverage and I went to one of the weight loss companies and they a got brand name covered. I pay $30/month because they said it was medically necessary.

I think my doctor didn’t want to do the paperwork or didn’t know how to write the appeal properly. There are so many online now. At least call and ask. Do you have any medical issues? I have a few in addition to obesity and had recent labs.

[Anonymous]

My NP is allegedly writing appeals (she literally said I didn’t need to do anything when I asked) but nothing comes of it. I think she either doesn’t know how, or there’s something wrong with my insurance (they are pretty good about approving everything else though!)
I am too lazy to follow up but I am thinking about switching the PCP

[Anonymous]

Use Call On Doc which is the telehealth for Lilly Direct. They will do an appeal for you.

[Anonymous]

Anonymous wrote:Been on it since May, switched insurance and denied during prior authorization.

Now the doctors office says they don’t do appeals…so it’s on me?

Wegovy IS covered…it was just denied because it wasn’t making progress? But I’m not at maintenance dose. I’ve lost 15 pounds.

What are my options:
Use an online doctor who might be savvy at getting approvals (Midi)
Appeal myself?
…something else?

I am really disheartened at the denial AND lack of help.

Ro.co

[Anonymous]

Anonymous wrote:Call the insurance company. Their default is no. Argue a bit. Mention this was prescribed by the doctor, and denying coverage opens them up to law suits. I wish that approach didn't work, but it does.

I’ve been working in appeals for/against insurance companies for a decade now. It absolutely does not work.

[Anonymous]

Anonymous wrote:My NP is allegedly writing appeals (she literally said I didn’t need to do anything when I asked) but nothing comes of it. I think she either doesn’t know how, or there’s something wrong with my insurance (they are pretty good about approving everything else though!)
I am too lazy to follow up but I am thinking about switching the PCP

So many providers submit appeals that are utterly useless. The denial might list a lack of notation of prior weight loss effort, current nutrition and exercise plan and the appeal submitted doesn’t even vaguely address any of those points. That is not getting overturned.