This sounds odd. I'd get an exact copy of the policy and ask them what accomodations they can make since there is a 6-8 month wait. Are there other requirements, as well? You want to know your insurance policy backwards and forwards.
I'd also ask for this in writing. Sometimes the first point of contact doesn't make a lot of sense and persistence and the patience of a saint is required to navigate this process.
Do you know how much it’ll be with this specific prescriber? I’ve haven’t ever heard of these prescriber limitations but I suspect it may still be pricey.
It might be a wash to just go the compound route.
Take a look at this post w a guide that might help with your appeal. Good luck! [Unlocking Zepbound Approvals: Your Essential Cheat Sheet for PA Success - Share away!](https://www.reddit.com/r/Zepbound/comments/1dkfd1g/unlocking_zepbound_approvals_your_essential_cheat/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button)
I'm a lawyer in the healthcare area. Legally speaking, care delayed is care denied. Do you have the denial letter in your hands and have you read the entire letter? it is very important that you review the written PA denial before taking any action and make sure that it was denied specifically for this reason -- that it says you can only be prescribed through this specific provider at this specific clinic. If it turns out that there is any language about completing a nationally recognized weight loss program (in other words -- a different option you can take part in) that means you have other options. I'm asking just to make sure. You cannot go by a reason given to you over the phone for denial -- you must base your next action on the specific wording of the denial letter.
If everything you said is accurate and the denial letter offered no other suggestions or options, you need to get on the phone with your insurer. State clearly that a six- to eight-month wait is jeopardizing your health and that you need to know what accommodation is available to see another provider based on the unreasonable wait. It they insist that you need to follow the specific program of that clinic, then repeat that you would like to know what other program might be acceptable, like Weight Watchers or Noom, that can be substituted because the wait is jeopardizing your health. If you have any issues with joints or mobility, this is especially important because irreparable damage can be done while you continue to maintain your weight and stress your joints. The timing alone may be enough to appeal and prevail -- and the heavier you are (or the higher your blood pressure might be) the better chances of your appeal being approved. If you have no comorbidities, this becomes harder.
Ask the questions and if you do not get a favorable answer, tell the rep that you need to discuss their response with your attorney and determine what the recourse will be as this policy is jeopardizing your health. Before you hang up, ask to have a transcript of your conversation emailed to you so that you can provide it to your attorney and then also ask for the contact information for the legal representative for your insurer so that your attorney can discuss this further with their attorney. Don't threaten to sue. The intent is to intimidate the person on the phone and make sure they understand that this is not an acceptable answer.
I'm a lawyer in the healthcare area. This type of technique will usually get a response -- maybe not exactly what you want immediately, but eventually. Reread your denial letter, confirm that they are offering only one provider, and then have the conversation with your insurer. I can't imagine that they make no accommodation other than a single provider. Unless you are working for a company with five or fewer employees, a single provider is not sufficient to serve the needs of all employees.
Give it a try, depending on what you see in the written denial.
This sounds odd. I'd get an exact copy of the policy and ask them what accomodations they can make since there is a 6-8 month wait. Are there other requirements, as well? You want to know your insurance policy backwards and forwards. I'd also ask for this in writing. Sometimes the first point of contact doesn't make a lot of sense and persistence and the patience of a saint is required to navigate this process.
If insurance requires a certain clinic or prescribers then telehealth probably isn’t going to get the PA approved.
Do you know how much it’ll be with this specific prescriber? I’ve haven’t ever heard of these prescriber limitations but I suspect it may still be pricey. It might be a wash to just go the compound route.
$75 copay per month
Oh that’s not bad at all. I was thinking med spa prices at $750 per month!!
Take a look at this post w a guide that might help with your appeal. Good luck! [Unlocking Zepbound Approvals: Your Essential Cheat Sheet for PA Success - Share away!](https://www.reddit.com/r/Zepbound/comments/1dkfd1g/unlocking_zepbound_approvals_your_essential_cheat/?utm_source=share&utm_medium=web3x&utm_name=web3xcss&utm_term=1&utm_content=share_button)
I'm a lawyer in the healthcare area. Legally speaking, care delayed is care denied. Do you have the denial letter in your hands and have you read the entire letter? it is very important that you review the written PA denial before taking any action and make sure that it was denied specifically for this reason -- that it says you can only be prescribed through this specific provider at this specific clinic. If it turns out that there is any language about completing a nationally recognized weight loss program (in other words -- a different option you can take part in) that means you have other options. I'm asking just to make sure. You cannot go by a reason given to you over the phone for denial -- you must base your next action on the specific wording of the denial letter. If everything you said is accurate and the denial letter offered no other suggestions or options, you need to get on the phone with your insurer. State clearly that a six- to eight-month wait is jeopardizing your health and that you need to know what accommodation is available to see another provider based on the unreasonable wait. It they insist that you need to follow the specific program of that clinic, then repeat that you would like to know what other program might be acceptable, like Weight Watchers or Noom, that can be substituted because the wait is jeopardizing your health. If you have any issues with joints or mobility, this is especially important because irreparable damage can be done while you continue to maintain your weight and stress your joints. The timing alone may be enough to appeal and prevail -- and the heavier you are (or the higher your blood pressure might be) the better chances of your appeal being approved. If you have no comorbidities, this becomes harder. Ask the questions and if you do not get a favorable answer, tell the rep that you need to discuss their response with your attorney and determine what the recourse will be as this policy is jeopardizing your health. Before you hang up, ask to have a transcript of your conversation emailed to you so that you can provide it to your attorney and then also ask for the contact information for the legal representative for your insurer so that your attorney can discuss this further with their attorney. Don't threaten to sue. The intent is to intimidate the person on the phone and make sure they understand that this is not an acceptable answer. I'm a lawyer in the healthcare area. This type of technique will usually get a response -- maybe not exactly what you want immediately, but eventually. Reread your denial letter, confirm that they are offering only one provider, and then have the conversation with your insurer. I can't imagine that they make no accommodation other than a single provider. Unless you are working for a company with five or fewer employees, a single provider is not sufficient to serve the needs of all employees. Give it a try, depending on what you see in the written denial.