GLP-1 CollectiveIf you have insurance
What your plan is
actually deciding.
A plan does not simply say yes or no. It applies a set of rules that it will tell you about if you ask, and each one has a way through it. Knowing which rule you are up against is most of the work.
The four rules
What stands between you and a filled prescription.
Prior authorization
Your plan will pay, but only after your prescriber submits paperwork showing you meet its written criteria. This is the most common answer, and it is not a denial. Ask your prescriber's office who submits it and when it went in, because an unsubmitted prior authorization looks exactly like a slow one.
Step therapy, also called fail first
The plan requires you to try something cheaper before it will pay for what you were prescribed. That may be a different GLP-1, an older weight-loss medication, or a documented period of diet and exercise support. Ask which specific steps are required and how long each one has to last, and ask whether your history already satisfies them, because treatment you had years ago often counts if it is documented.
A preferred product
Most plans cover one GLP-1 on better terms than the others, and that choice is renegotiated every year. If your plan prefers a medication your prescriber did not choose, the fastest route is often a new prescription for the preferred one rather than an appeal for the other.
An exclusion
Some employer plans exclude medications for weight loss entirely while covering the same molecules for type 2 diabetes. An exclusion is not a coverage decision, so an appeal will not usually move it. What can move it is the employer, because the employer chose the exclusion and can drop it at renewal.
Before you call
Five questions for the number on your card.
- Is this medication on the formulary for my plan? Give them the exact name and dose. Coverage can differ between two plans from the same insurer.
- Does it need prior authorization, and what are the written criteria? Ask them to send the criteria to you. You are entitled to them, and they tell your prescriber exactly what to document.
- Is there step therapy, and what counts as having completed it?
- Which GLP-1 does my plan prefer? This one question saves weeks when the answer is a medication you can start on now.
- Does my plan exclude weight-loss medications? If the answer is yes, ask whether coverage exists for another approved use you may qualify for, such as sleep apnea or cardiovascular risk.
Write down the date, the time and the name of whoever you spoke to. If you appeal later, that record is evidence.
If you are denied
A denial is a decision, and decisions can be appealed.
Appeals succeed often enough to be worth making, and the process is defined in law for most plans rather than left to the insurer.
The deadlines
You have 180 days from the denial notice to file an internal appeal. The plan then has 30 days to decide if you have not yet had the medication, or 60 days if you are asking to be reimbursed for something you already paid for. An urgent case has to be decided as fast as your condition requires and within four business days.
What to send
Send the denial letter, the explanation of benefits, your written request, and anything from your prescriber that speaks to the plan's own criteria. A letter of medical necessity from the person who prescribed it carries more weight than anything you can write on your own, so ask for one and give the office the criteria you obtained.
External review
If the internal appeal fails, an independent reviewer outside the insurance company can look at it, and the plan has to follow that decision. In urgent situations you can ask for both at once rather than waiting.
A draft to start from
Our appeal letter builder writes a first draft in your browser from what you type, with nothing sent anywhere. Print it, correct it, and take it to your prescriber.
If your plan does cover it
A manufacturer savings card can bring a covered prescription down to as little as twenty-five dollars a fill, within monthly and yearly caps. The savings cards explains which card applies and what the caps are. These cards are closed to anyone with Medicare, Medicaid or other government coverage, which Medicare and Medicaid covers instead.