Just wanted to share my prior authorization saga for Zepbound (tirzepatide for obesity) in case it helps anyone else navigating this nightmare.
My stats: BMI 36.4, no T2D, diagnosed with obesity + hypertension + prediabetes (A1C 5.8%). Employer-sponsored BCBS PPO plan.
Timeline:
- Jan 3: Endo submits PA for Zepbound. Includes letter of medical necessity, labs, documented failed diet attempts.
- Jan 18: Denied. Reason: "Patient has not failed formulary alternatives (orlistat, phentermine/topiramate)"
- Jan 22: Endo submits appeal with documentation that I tried phentermine in 2023 (lost 8 lbs, regained 12). Also notes orlistat is inappropriate given my GI history.
- Feb 8: Second denial. "Insufficient documentation of failed therapy."
- Feb 12: Endo does peer-to-peer review with insurance company's medical director.
- Feb 14: APPROVED!!!! 🎉🎉🎉
The peer-to-peer was the magic bullet. My endo said the insurance company's medical director basically agreed it should have been approved the first time but the automated review process denied it.
Total time from first submission to approval: 42 days.
42 days is actually fast. I'm on day 67 and still fighting. UHC has denied me THREE times. My BMI is 41 with documented sleep apnea and I've tried and failed phentermine AND contrave. They keep saying "not medically necessary."
My endo is doing a peer-to-peer next week. Praying it works because I'm running out of options. The system is broken.
Former insurance industry worker here (left because I couldn't stomach it anymore, pun intended). Some tips that actually work:
- ALWAYS request a peer-to-peer. Most denials are processed by algorithms or non-physician reviewers. The peer-to-peer forces an actual doctor to look at your case.
- Get the specific denial reason in writing. Call the number on the denial letter and ask for the specific clinical criteria they're applying. Then address EXACTLY those criteria in your appeal.
- Document EVERYTHING. Every diet attempt, every medication trial, every comorbidity. Date, duration, results, reason for discontinuation.
- Use Lilly's support team. They have people whose entire job is helping patients navigate PA. They know the specific criteria for every major insurer.
- File with your state insurance commissioner if internal appeals are exhausted. This is nuclear option but it works surprisingly often because insurers hate regulatory scrutiny.
- Check if your employer's benefits team can help. Large employers often have direct relationships with insurers and can escalate cases.
The dirty secret: most first-round PAs are denied automatically. It's a cost-containment strategy. They're betting a percentage of patients will give up. Don't give up.
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View Resultsthat's incredibly helpful, thank you. The point about it being a cost-containment strategy makes me angry but also explains a lot. My endo's office said the same thing — "they deny everyone the first time, just appeal."
It shouldn't be this hard to access a medication that your doctor says you need. 😤
I gave up on insurance and went compounded. Paying $250/month out of pocket. Is it ideal? No. But I wasn't going to wait 3 more months fighting a bureaucracy while my health deteriorated.
I know compound is controversial on here but it's the reality for a lot of us.