Can someone help with this doctor and prior authorization snafu?

[Anonymous]

I was only in Wegovy from May-Sept and it changed my life. Mental health, weight loss.

Insurance change on Sept 1 due to job change. I’ve been off Wegovy since then. My doctor submitted TWO “continuation of Rx” and it was denied. I called insurance and they said it should have been INITIAL. Now it needs an appeal (denied twice) but Dr won’t do it.

I called insurance and they highly recommend having a doctor send it. But she won’t. I meet all the criteria: bmi is high and I have related weight issues. I’m so mad the doctor won’t write the appeal since she messed it up.

Can I find another doctor to send the prior authorization (initial) or does insurance know I’ve been rejected twice? Is it by doctor or medication? I worry if I call again then I’ll be boxed out of finding another doctor.

I’m frustrated and sad. Should I try Midi? Are online Dr better at getting approvals?

[Anonymous]

Interesting you are frustrated with your doctor and not the stupid hoops your insurance company is making you jump through…

[Anonymous]

You sound like an adduct, OP!

[Anonymous]

You can do the appeal yourself

[Anonymous]

Anonymous wrote:Interesting you are frustrated with your doctor and not the stupid hoops your insurance company is making you jump through…

I called insurance and they said the doctor submitted it twice as a "continuation of coverage", which was a mistake. It should have been initial. After the first rejection, I told this to the doctor. She submitted it as continuation again. Now, it's been denied twice, which automatically bumps me to appeals.

[Anonymous]

Anonymous wrote:You can do the appeal yourself

I know I CAN, but will it even be accepted?

[Anonymous]

Anonymous wrote:

Anonymous wrote:You can do the appeal yourself

I know I CAN, but will it even be accepted?

Not if the initial ones were wrong.

[Anonymous]

Anonymous wrote:Interesting you are frustrated with your doctor and not the stupid hoops your insurance company is making you jump through…

Every job has administrative responsibilities, many of which can be frustrating. That doesn't mean you can just ignore them if you don't like doing them.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:You can do the appeal yourself

I know I CAN, but will it even be accepted?

Not if the initial ones were wrong.

They were sent as continuation of coverage, not initial. I hope I can clearly write that in the appeal?

[Anonymous]

It is a continuation of Rx. It is initial request under this plan. I can see why your doctor won’t say it’s an initial prescription because that contradicts your medical records.

[Anonymous]

Anonymous wrote:It is a continuation of Rx. It is initial request under this plan. I can see why your doctor won’t say it’s an initial prescription because that contradicts your medical records.

I called the insurance directly and they said it should be initial. Continuation only applies if you have reached maintenance dose, and I have not. I have only been on it for 3 months.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:You can do the appeal yourself

I know I CAN, but will it even be accepted?

Not if the initial ones were wrong.

They were sent as continuation of coverage, not initial. I hope I can clearly write that in the appeal?

That's not an appeal. You need a doctor to resubmit. If they reject a properly submitted one, then you can appeal that.

[Anonymous]

If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

[Anonymous]

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

[Anonymous]

Anonymous wrote:

Anonymous wrote:If you are able, I’d suggest researching the criteria to get the medicine in the first place, and also to continue it, and then write up an appeal on your own. You can probably find samples online. You might want to request supporting records from the physicians’ offices to support the appeal. Them take the whole thing, with a pen, along with a draft on a new flash drive, make an appointment, and give it to the doctor to sign and submit.

If that doesn’t work you need a significantly better doctor.

I meet the criteria. I have called, and checked. The doctor "does not do appeals.'

Finding a new PCP might take months. I might try Midi, but I don't know if insurance will let me start all over.

It will, so you should start the process of switching doctors now.