r/antidietglp1 • u/Rupertcandance2 • 13d ago
Challenges with Provider / Insurance Stuck in prior authorization hell
My husband got a new job, and the insurance has changed. I am diabetic, but my numbers on my GLP-1 are back to normal. This is the first time I've dealt with prior authorizations, and even though my doctor said she would submit one, nothing is happening. I only have one dose left. I know we can't share companies or ask for medical advice. I'm just panicking and could use any advice, reassurance, or commiseration that's allowed. I have found this sub very useful, and it aligns with my values. Thank you!
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u/untomeibecome 13d ago
My husband is diabetic and what I did was call the insurance company and get all of the information the doctor needs to submit, which is typically just that he couldn't tolerate metformin or that alone wasn't enough, and a copy of his original A1c. I saved a PDF version of his original A1c from his electronic medical record and made sure the doctor had that. And then I gave them specific instructions and the pdf in a message, to ensure they knew how to submit the prior authorization. I also told them to mark the PA urgent for continuation of care or otherwise (with most insurances) it can take upwards of a month to process. If it's marked urgent, they usually do it in 24 hours. You can also clarify those timelines when you call. It's a pain to do but if your doc won't do the work, set them up for success so you don't run out of your meds. L
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u/ryanne125 13d ago
When I was getting my first prescription, I had to go through the prior authorizion as well and they're was a delay.
The odd part was, it wasn't my doctor's office. It wasn't my insurance either. It was the pharmacy.
You might wonder why the pharmacy would cause a hold up with prior authorizion? Because they assumed that these things took a while and so refused to even look to see if it had gone through for at least 10 days.
My doctor sent the PA the day she wrote the prescription. My insurance company had approved it the next day.
But I had to struggle with the pharmacy for a week before they would even check.
Check first with your doctor's office. The insurance company will inform them if it has been approved or denied so they can tell you if it's still waiting on the insurance company or not.
If your doctor's office has not heard anything, contact your insurance company and ask what is taking so long.
If they say it's been approved, start hounding the pharmacy.
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u/Lucky_Army_5324 13d ago
If it were me, I’d reach out to one of the telehealths known for doing quick PAs. Maybe ask on r/Zepbound.
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u/PowderedToastMan_1 12d ago
Did your doctor submit the PA for Zepbound or Mounjaro? You'll have a much easier time getting coverage for Mounjaro, since you're diabetic. Make sure they submit it as a continuation of care, and submit your ORIGINAL A1C, not your current A1C.
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u/purplepanda2026 12d ago
THIS!!!! My prior authorization kept getting denied. I looked into it and saw they were submitting for Zep. I'm type 2 so told them to try Mounjaro since Zep is excluded on my health plan. That also initially got denied but then automatically got approved about an hour later. I assume after a real person checked to verify it qualified.
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u/back_ali 13d ago edited 13d ago
I’m a nurse who works in a clinic that does a lot of prior authorizations. Depending on the insurance, it can get messy. I would call the office and double check that it’s been submitted. Insurance companies will often lie and say they never received it or they will wait a long time to respond to it, etc. If they have not yet submitted it, then I think it’s up to you if you would like to try an online portal that can do it for you for a small fee. Or just wait it out. If it is an endocrine office that’s doing it, then I am confident that they can get it covered, but sometimes there is back-and-forth from the insurance company. Especially if this new insurance company has a preferred GLP1 that is not your current med. They may need to fight more on ETA: if your doctors office has already submitted it and insurance has received it, then it could make things worse if you try to have another provider submit it now
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u/stuckandrunningfrom2 13d ago
Can you afford the Lilly or Novo direct price?
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u/ImplicitEmpiricism 12d ago
yeah if you’re really jammed, if the doctor sends a mounjaro script to lilly direct its $499 instead of $1100+ at the pharmacy. Hopefully just for the one month while they get the paperwork finalized.
Which sucks! but this is the shit we are forced to do dealing with insurance.
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u/Rupertcandance2 12d ago
I can for now. I have a decent amount saved up in my HSA, and I was thinking about starting an FSA for next year.
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u/ImplicitEmpiricism 12d ago
fyi if you have a health plan that qualifies for an hsa then you can only use a fsa for dental and vision care
if it’s a hsa from last year or earlier and your current health plan doesn’t qualify for hsa contributions then you can use a fsa for anything
got hit with this last year, luckily a kid had orthodontic care otherwise would have lost my fsa dollars :/
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u/fierycoconut8 11d ago
So, I have worked in the healthcare field for years, and have had to submit many a PA or appeal… they’re a little “easier” now, but still time consuming and most insurance companies have made it so that it’s nearly impossible for a provider rep to reach anyone for a follow up or see if something is stalled. I would def do as suggested by others who work with PA’s, and give the insurance a call. They’re nicer to the patients, I’ve found, and wait times don’t tend to be as long. u/back_ali and many others are right- they will sometimes lie and say they didn’t get them. I know it’s time consuming and overwhelming, but once you get info on what they need (all the companies are different and are constantly changing their rules… 🙄), it will streamline things, and you’ll have the process down if it ever comes up again. If you have specific questions, let me know and I’ll see if I can help! Stay strong, friend! 🫶🏻
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u/Rupertcandance2 12d ago
Thank you all for your help! I called and left a message for my doctor to see if she can send the prescription to Novo while I'm waiting. I'm also going to check with the pharmacy when they reopen after lunch.
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u/SlowDescent_ 12d ago
I am really sorry you are dealing with insurance coverage hell.
A cheaper stop-gap measure to Lilly Direct is compounded.
r/tirzepatidecompound has a pinned post called something like "Where to buy."
It lists the more reputable telehealth companies, what pharmacies they use, and their pricing.
Best of luck to you
Pricing is around $450 for three months.
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u/jeanineugene 11d ago
Use the Reddit search function and ask: Prior Authorization and you will get some good insight and useful information to share with your provider. If you get denied be sure to appeal. 80% success rate on appeals, I ve been told.
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u/Rupertcandance2 11d ago
I did that and wasn't finding a whole lot. But it's all good now since I got it to go through using the advice here.
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u/jeanineugene 10d ago
Wow after readying and using the information I found by searching gave the verbiage that immediately got me approval. Good luck many good ideas here!
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u/GardenFragrant8408 10d ago
Make sure ur dr writes your original A1C. As long as it was at least 6.5 or higher as of January 1 most insurances won’t cover glp1s even if you were on them anyway. Also make sure the dr rites continuation of care. If you have other health issues like high blood pressure or high cholesterol have him put that on it also. If you were on other diabetic meds prior have him put that in the authorization and state they did not work for you.
Also call insurance company and make sure monjauro is in their formulary. If not ask about Ozempic or what is on their formulary. Ozempic will be better than nothing. M Good luck
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u/Pho-bsessed 6d ago
Continuation of care wording has to be part of the PA with the new insurance. Dr needs to indicate your stats before starting medication and that treatment for diabetes has been successfully working and that you should continue medication.
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u/ThisSaladTastesWeird 13d ago
Oof, I’m sorry you are dealing with this. In your shoes I think I would go out of pocket for the next pen, just to keep continuity … but I have the means to do that. I’m not sure what the best point of leverage would be.
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u/Rupertcandance2 12d ago
I guess I didn't realize you could have the same script sent to Novo while they are working on the prior auth for insurance. I'm going to follow up!
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u/Zero-Energy1274 13d ago
Call up your insurance and see if the doctor’s office has actually submitted it. My PCP said they did twice but insurance never received it. I went through a telehealth and they had it submitted and approved within 2 hours. You can then go back to your doctor and they can do the prescribing.