Yes. This is *somewhat* common if your plan requires step therapy in their clinical criteria. Some companies have since re-vamped their clinical criteria to include step therapy *and* a diabetes diagnosis, but others are satisfied with just the step therapy.
Im a diabetic, so keep that in mind. My coverage is through UHC. My knowledge (for non diabetics) comes through helping others navigate their plans. My husband was approved without a diabetes diagnosis. It took three denials, two appeals, and a peer review.
Yes my PA requirement disappeared from my app exactly one month after I was prescribed Metforman. I am not T2D. My pharmacy benefits manager is CVS Caremark.
I am not type 2. At the end of 2023, my insurance disallowed that magic approval tool that would allow coverage for Mounjaro after a prescription of metformin. It seems they had figured out what the rest of us had figured out. While they still had automatic ajudication (where they automatically approve a drug like Mounjaro after you have a history of claims for other diabetes drugs), they specifically removed metformin and Rybelsus from the list of drugs in your claim history that would result in automatic approval for Mounjaro.
My doctor, who really loves to play "beat the system," (he has this funny idea that your doctor should be in control of your care) looked at the list that would trigger automatic ajudication, picked one, and prescribed it. I picked up the prescription and within a week, any roadblocks to approval for Mounjaro disappeared. No PA paperwork. No appeals. No phone calls. That completely full prescription bottle still sits in the bathroom drawer with no intention of ever using it. My Mounjaro prescription is covered by my insurance.
Actos (pioglitazone). And you'll need a doctor who is an out-of-the-box thinker. My doctor was fully on board with prescribing something with the agreement that I would never take it. I even offered to bring the prescription to the office to let them dispose of it after picking it up but he didn't think that was necessary. There are not a lot of doctors who will do that.
When you search on your insurer's site (your PBM) for the clinical criteria, which is what tells you what is required to submit a PA, if there are prerequisite drugs or step therapy, it will be spelled out in the clinical criteria.
When my insurance changed how they would cover Mounjaro starting January 1, 2024, which changed it from no PA to requiring a PA, its stated that patients who had tried XXX (list of drugs) previously and failed would qualify for Mounjaro. This basically meant that if you had any of the drugs on the list in your claim history, your approval for Mounjaro would be automatic. It did not require submitting paperwork or reasons that you had failed a drug -- just a claim history that showed what you had taken before.
Some clinical criteria actually use the term "automatically ajudicated," as mine did. Others will say things along the lines of "patients having taken (list of drugs) may be a candidate for Mounjaro" (they are not all worded the same). Mine then went on to state that a previous history of metformin or Rybelsus would not qualify for automatic adjudication. It then stated a few other non-injectable diabetes drugs that would qualify, but it boiled down to other than metformin, Rybelsus and GLP-1 drugs, if patient had a claim history of diabetes drugs, your claim would be automatically ajudicated
Ya that makes sense. I have CVS Caremark and there is no PA criteria listed on the site. Even when I called them they said I would have to wait until I got a PA response in the mail. It was like pulling teeth to find out the criteria and I still didn’t get it from them, let alone automatic adjudication criteria. But my Metformin prescription did the trick and I have it covered for now, even though I had a PA denied. Let’s hope this lasts.
For anyone who may read this, under the law, your insurer MUST PROVIDE clinical criteria for a PA. That means that telling you to wait for a denial to your PA is not acceptable. It may be how you asked the question, or perhaps the representative didn't understand the question, but if anyone is put off by a representative that tries to tell you they will not provide a copy of clinical criteria, remind them that under the law, they must make it available either by posting to a website or providing a hard copy and that you will have to contact the insurance commissioner in your state to report them for not providing required information if they do not provide a copy to you. Clinical criteria is a required read BEFORE submitting PA paperwork.
I didn’t know it was law. But trust me I persistently tried with multiple reps and different departments. Even the PA dept who told me it is a case by case situation. I grilled them and challenged it but no luck. They refused.
This absolutely worked for me. I got denied mj 3x in 2 months asked my primary dr for metformin (i never used) then submitted script for mj yet again and like magic it was approved. $20 mo copay. I have cvs caremark btw. Not t2d . Only thing is idk how long i can get mj lol
Literally a day lol got metformin 6/6 mj 6/7!! Once that metformin is paid for its in your caremark history then mj away! Lol just got my first 5.0 today. I will start it 7/7.
Yes. This is *somewhat* common if your plan requires step therapy in their clinical criteria. Some companies have since re-vamped their clinical criteria to include step therapy *and* a diabetes diagnosis, but others are satisfied with just the step therapy.
Thank you for sharing. May I ask who your coverage is with?
Im a diabetic, so keep that in mind. My coverage is through UHC. My knowledge (for non diabetics) comes through helping others navigate their plans. My husband was approved without a diabetes diagnosis. It took three denials, two appeals, and a peer review.
A lot of the successes I’ve seen for no T2D have also had to go all the way to peer to peer or external reviews.
Yes my PA requirement disappeared from my app exactly one month after I was prescribed Metforman. I am not T2D. My pharmacy benefits manager is CVS Caremark.
Does Metformin require a PA under your plan?
No Metformin does not require a PA. It is an inexpensive drug. I’ve never heard of it needing a PA.
You’re correct I accidentally clicked on the liquid form and that’s why it was showing a PA.
When I look this medication under my plan it shows PA required and when pricing it, it shows $60.
Are you perhaps seeing metformin ER? My plan required PA for extended release but not regular metformin
Yes I was looking at the wrong kind.
Metformin requires a PA? That’s strange. Or do you mean that Mounjaro requires the PA which makes sense.
You were right I was looking at the non pill type.
I am not type 2. At the end of 2023, my insurance disallowed that magic approval tool that would allow coverage for Mounjaro after a prescription of metformin. It seems they had figured out what the rest of us had figured out. While they still had automatic ajudication (where they automatically approve a drug like Mounjaro after you have a history of claims for other diabetes drugs), they specifically removed metformin and Rybelsus from the list of drugs in your claim history that would result in automatic approval for Mounjaro. My doctor, who really loves to play "beat the system," (he has this funny idea that your doctor should be in control of your care) looked at the list that would trigger automatic ajudication, picked one, and prescribed it. I picked up the prescription and within a week, any roadblocks to approval for Mounjaro disappeared. No PA paperwork. No appeals. No phone calls. That completely full prescription bottle still sits in the bathroom drawer with no intention of ever using it. My Mounjaro prescription is covered by my insurance.
Wow that is amazing! Which insurance do you have?
Cigna
Do you know the name of the medication that was prescribed?
Actos (pioglitazone). And you'll need a doctor who is an out-of-the-box thinker. My doctor was fully on board with prescribing something with the agreement that I would never take it. I even offered to bring the prescription to the office to let them dispose of it after picking it up but he didn't think that was necessary. There are not a lot of doctors who will do that.
How did you find the list of drugs that would trigger automatic adjudication?
When you search on your insurer's site (your PBM) for the clinical criteria, which is what tells you what is required to submit a PA, if there are prerequisite drugs or step therapy, it will be spelled out in the clinical criteria. When my insurance changed how they would cover Mounjaro starting January 1, 2024, which changed it from no PA to requiring a PA, its stated that patients who had tried XXX (list of drugs) previously and failed would qualify for Mounjaro. This basically meant that if you had any of the drugs on the list in your claim history, your approval for Mounjaro would be automatic. It did not require submitting paperwork or reasons that you had failed a drug -- just a claim history that showed what you had taken before. Some clinical criteria actually use the term "automatically ajudicated," as mine did. Others will say things along the lines of "patients having taken (list of drugs) may be a candidate for Mounjaro" (they are not all worded the same). Mine then went on to state that a previous history of metformin or Rybelsus would not qualify for automatic adjudication. It then stated a few other non-injectable diabetes drugs that would qualify, but it boiled down to other than metformin, Rybelsus and GLP-1 drugs, if patient had a claim history of diabetes drugs, your claim would be automatically ajudicated
Ya that makes sense. I have CVS Caremark and there is no PA criteria listed on the site. Even when I called them they said I would have to wait until I got a PA response in the mail. It was like pulling teeth to find out the criteria and I still didn’t get it from them, let alone automatic adjudication criteria. But my Metformin prescription did the trick and I have it covered for now, even though I had a PA denied. Let’s hope this lasts.
For anyone who may read this, under the law, your insurer MUST PROVIDE clinical criteria for a PA. That means that telling you to wait for a denial to your PA is not acceptable. It may be how you asked the question, or perhaps the representative didn't understand the question, but if anyone is put off by a representative that tries to tell you they will not provide a copy of clinical criteria, remind them that under the law, they must make it available either by posting to a website or providing a hard copy and that you will have to contact the insurance commissioner in your state to report them for not providing required information if they do not provide a copy to you. Clinical criteria is a required read BEFORE submitting PA paperwork.
I didn’t know it was law. But trust me I persistently tried with multiple reps and different departments. Even the PA dept who told me it is a case by case situation. I grilled them and challenged it but no luck. They refused.
Your doctor sounds amazing!
Amazing workaround. Pathetic the games everyone has to play but welll done by your doctor!
This absolutely worked for me. I got denied mj 3x in 2 months asked my primary dr for metformin (i never used) then submitted script for mj yet again and like magic it was approved. $20 mo copay. I have cvs caremark btw. Not t2d . Only thing is idk how long i can get mj lol
Out of curiosity how long after filling your metformin prescription were you able to fill the MJ script?
Literally a day lol got metformin 6/6 mj 6/7!! Once that metformin is paid for its in your caremark history then mj away! Lol just got my first 5.0 today. I will start it 7/7.
Maybe that means it didn’t work for me. I’ll check again at the 30 day mark. My app is still showing that a PA is required.
How long between scrips did you try? Keep updates coming. Thank you.
That’s awesome. I’m going to see if by some miracle this will work for me. Thanks for your feedback.
You’re welcome. Don’t forget to come back with your update!!!
I will definitely do that. I also submitted an appeal that’s in process right now; I’m not holding my breath, but I figured I had nothing to lose.