GLP-1 insurance Prior Authorization

Type 1 and LADA
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I am T1D and have used Mounjaro for the last year. Not to lose weight, but to suppress my voracious appetite. It’s been a game-changer for me. My A1c dropped from ~7.5 to ~6.5. My BG StDev is lower. I sleep better. My insurance (Aetna) required prior authorization renewal and rejected doctor’s request. I want to appeal and figure my doctor probably sent in generic letter. Any recommendations on specific wording that can be used in appeal letter? I’m going to write the letter and let my doctor sign it.

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Just a note that the Discourse system flagged this post as possible spam. Poster is in good standing and I don’t see any issue so I’ve restored it.

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I’m in the middle of a couple of grievances with my health plan. I hope you are more successful. Some recommendations:

  1. Insurance companies have been busted for denying PAs in bulk so it is possible they never even looked at the request your doc submitted. First thing to do is have your doc resubmit a slightly different PA request. Also, insurance companies have 30 days to respond to grievances but have to decide on PA’s faster depending on your state.
  2. Double check that the PA and grievance go to Aetna and not the PBM. For example I’ve got a health plan from Anthem but the prescription benefits are handled by OptumRX and any drug PA denial grievances go to Optum.RX. Maybe you’ll get lucky and found your doc should have sent the PA to the PBM like they did previously and no grievance will be required.
  3. From the Mounjaro prescribing information: “MOUNJARO is not indicated for use in patients with type 1 diabetes mellitus.” Check with your doc if any other drugs might work. Don’t mention T1D in a grievance.
  4. Get a copy of the PA request submitted by your doctors office that resulted in denial and the last request that was approved.

Good luck!

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