There is a lot of crap that they’re able to instantly deny through your plan’s terms and conditions.
It’s worth reading the plan summary of what won’t be covered, even if it’s prescribed treatment. Some of the shit that’s hidden in there is fucked up.
This year someone in my family started to have to pay out of pocket for their GLP1s because their diseases didn’t progress far enough for the treatment to be covered. They’d rather you hurry up and die than pay for expensive drugs that keep you alive for longer.
If they have cardiovascular disease or kidney disease, those are getting added as indications for the GLP-1’s so they might be able to resubmit the authorization/claim with those diagnosis codes added to get it covered.
Yeah, but the problem is, if tests / labs show the precursor indicators for those diseases, and you have a family history, they’ll still deny until you actually have the something like a heart attack or stroke.
GLP-1s are the hot new thing, but it’s pretty common for insurance companies to deny expensive preventative care, even after all other avenues have been thoroughly explored.
In my family medicine rotation a couple months ago, we got it approved for someone with pre-diabetes, high blood pressure, and stage 2/3 kidney disease (which is not very advanced. A lot of people over the age of 35-40 can technically fall into stage 1/2.)
