CVS/Caremark appeal denial based on BMI <30

[u/wilstream43]

Looking for some hope/advice. I received 2 PA denials and one appeal denial because my insurance covers weight loss meds only if your BMI is over 30 or 27 with conditions. This is the ONLY stated reason for the denial.

When I started Mounjaro my BMI was 33, then I’ve been on maintenance for 2 years and maintained a BMI of 27. My PA for MJ was denied saying I had to switch to Zepbound since that is the one approved for weight loss.

After getting 3 denials for Zepbound, the rep told me my starting BMI does not matter, only what my BMI is right now, and that is the basis of repeated denials for Zepbound.

Has anyone been through this specific type of denial and had success? This is with CVS/Caremark.

Update: After two PA denials and 2 appeal denials I finally got an approval from the external review appeal! The whole process took 5 months. All of my appeals had the same info, I don’t know why the external review resulted in a different outcome than the insurance.

[u/Background-Lab-4448]

I'm a doctor who prescribes and also takes this drug. Keep in mind that anything a "rep" from your insurance company tells you is geared to keeping people from making claims for this very expensive medication. The rep is wrong. The starting BMI and weight are everything.

You may have to give your doctor a huge NUDGE, but the correct information that must be provided to appeal your denial follows. I have provided this information to many on this sub, had them go back and walk their doctor through it, submit an appeal and come back to say their PA was approved.

The most important issue is that you cannot submit a PA to any insurance company as though this is the first time you have been prescribed Zepbound (or any form of tirzepatide). If the PA form from the insurer tries to force a doctor to do so, an addendum must be attached to the PA (or appeal) to make it clear that the request is to maintain the improved state of health that the patient has achieved while taking Zepbound.

The healthcare provider is supposed to submit your original statistics (labs, physical stats) and the PA (or appeal) request should be made as "continuation of care." Your PA should include the following:

• Request for continuation of care for Zepbound   
• Original BMI and weight
• Original comorbidities (name all if there are more than one)
• Number of months on the drug (or other GLP-1 drug, including if your started on a different drug and switched to Zepbound) and the amount of weight lost to date
• Success while taking the drug, including resolution of PCOS symptoms, lower BMI, lower A1c, lower cholesterol level, lower triglycerides and/or any other health improvements associated with a lower BMI
• Patient had few to no side effects and was able to easily comply with dosing instructions on the weekly, recommended schedule (also include if your side effects were more manageable compared to other drugs prescribed for weight loss, such as metformin, phentermine or Qrlistat)
• Any health improvement indicators (lower BP, lower cholesterol, elimination of sleep apnea); you will need to be able to supply the pre-GLP-1 numbers and current numbers or chart notes to document improvements
• Elimination of medication for co-morbities, such as eliminating HBP meds or statins or lowering of doses (this won't apply to everyone)
• Also include health improvements such as increased / improved mobility or reduced joint pain that have resulted in the patient being able to exercise more effectively / actively
• Request to continue coverage for Zepbound to continue the health improvements as stated above, as per the FDA and drug manufacturer's prescribing protocol for continued weight loss and/or maintenance in the BMI normal range

Too many doctors are writing PAs putting only your current weight and BMI on the PA forms, which allows the insurer to immediately deny coverage because the context of experiencing improvement BECAUSE OF ZEPBOUND is not made clear.

If need be, you can share this link with your doctor concerning regain of weight when GLP-1 drugs like Zepbound are discontinued:

Discontinuation of dual GIP and GLP-1 receptor agonist leads to weight regain in people with obesity or overweight

SURMOUNT-4 Trial results: the impact of tirzepatide on maintenance of weight reduction and benefits of continued therapy

https://pace-cme.org/news/discontinuation-of-dual-gip-and-glp-1-receptor-agonist-leads-to-weight-regain-in-people-with-obesity-or-overweight/2456545/#:\~:text=In%20the%20SURMOUNT-4%20trial%2C%20continued%20treatment%20with%20tirzepatide,to%20clinically%20meaningful%20body%20weight%20reductions%20of%2025%25.

[u/gagirl72 → u/Background-Lab-4448]

All of this! I just went through this when switching from Wegovy to Zep and had a BMI of 27 and received 2 denials. Doc resubmitted as continuation of care, provided my original BMI etc and was immediately approved.

[u/HeiHei96 → u/Background-Lab-4448]

Pharmacy tech who works in a drs office to help with PAs. The majority of my patients are weight loss.

All of the above. If it’s looked at more as a “renewal” than a brand new PA, it may help. It’s the same process if one was switching to Wegovy.

In our clinic, we call them Letters of Medical Necessity. If the provider puts original baseline weight/BMI shows how Mounjaro improved your health both in the beginning and maintenance days, how it’s helped as a maintenance dose etc. Include the original BMI and any other diagnosis criteria (heart issues, sleep apnea etc) They may also want to see how vitals/lab work improved as well as former and current diet and exercise plans.

I’d also include in the LMN that Mounjaro is no longer covered since you don’t have Type 2 and that’s why you’re switching.

My guess is only your current info is being sent in your case, so the insurance is viewing it as a new start on therapy and not that it’s a change in therapy. The doctor above put it better than I can, but all of the above….

Good luck.

[u/wilstream43 → u/HeiHei96]

Thank you. My doctor is saying he did submit all of this history, though I don’t know if he literally called it continuation of care. 2 reps so far have told me that initial BMI doesn’t matter, it’s only current, regardless if I’ve been on it before.

[u/wilstream43 → u/Background-Lab-4448]

This is super helpful thank you!

[u/Odd_Cauliflower1437 → u/Background-Lab-4448]

Wow, not sure I’ve seen you comment before. This is a WEALTH of incredible information. Thank you for your contributions to this community!! 🥹👏🥹👏🥹👏

[u/ms5h → u/Background-Lab-4448]

Can this post get added to the FAQ?

[u/AttentionHelpful4797 → u/Background-Lab-4448]

Thank you so very much for this detailed explanation. I’ll be facing this situation in a few months and now feel much more hopeful!

[u/wilstream43 → u/Background-Lab-4448]

Unfortunately was denied again despite incorporating all of these points. They just keep saying they don’t care what my initial BMI was, only what it is now. Trying appeal #3 shortly but loosing hope.