Medicaid GLP-1 coverage — 12 month update

Dr.LipidDallas said:

sarah_TO said: ...my insurance denied cost and coverage coverage because...

Filing a mild objection. Mild because I might be wrong; an objection because nobody has addressed the case that does not fit. 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.

sarah_TO said:

Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the…

Insurance update relevant to cost and coverage: I just got my prior auth approved through Aetna after 2 attempts.

What finally worked: a letter from my endocrinologist documenting BMI history (>3 years), failed diet attempts, comorbidities (T2DM + hypertension), 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.

TrialNerd_Beth said:

The affordability discussion here usually stops at individual tactics.

TrialNerd_Beth 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.

Following on from fiona_VT — and this may be the naive question:

Did your prescriber agree with that reading, and if not what was their objection?

OP back with an update, since a thread like this is useless without one.

Update: approved on the third attempt after a peer-to-peer. Nothing about my case changed; only who was doing the talking.