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 follow-up is short relative to how long people actually take these drugs, so durability is an assumption here rather than a finding.
The bit I cannot resolve on my own is what actually works on a prior-authorisation denial, as opposed to the list of things that sound like they should work. Practical detail welcome, however dull — the duller the better.
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.
emily_PDX said:Denials are usually procedural rather than clinical, and the order that works reflects that.
emily_PDX 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.
emily_PDX said:Denials are usually procedural rather than clinical, and the order that works reflects that.
Pushing back on emily_PDX here. 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.
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Browse GL BiochemDr.NateNeph said:The affordability discussion here usually stops at individual tactics.
Insurance update relevant to cost and coverage: I just got my prior auth approved through Aetna 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.