Any resource for how to fight medication coverage decisions?
Are there some resources/playbooks/organizations that tell me how to approach a denied medication? I think my doctor's office has not been doing a good job on managing this so far. I seem to clearly qualify for it even according to the language in some of the denial letters, but the insurance ignores some of the evidence the doctor sent them, and after a couple of appeals, now there has been an "independent review" (NMR) with a denial.
This is for Wegovy, and the plan criteria say you need to have lost 5% of your starting weight for reapproval after 6 months. I have lost more than that, but the independent review quotes my weight loss for just one of the months, which is obviously less than 5%, so they say the medication is not working for me. How do I challenge this? My doctor's office (who also didnt send them weight info at first) basically just says "sorry they denied it". But it seems so obviously against the insurance's own criteria (this is CVS caremark via a Cigna high deductible plan).
Do I actually need to sue them? Should I demand my doctor to keep pushing? (the final letter said something about "lawsuits and other remedies may be available" without telling me what they are). What are my next steps?
I've been in the US for more than a decade (grew up on a much more "socialized" and scrutable health insurance system) and except for the mountains of paperwork and mysterious bills and refunds that show up for months or sometimes years, have not had any issues before now (due to good employer plans).
submitted by /u/Limitedservice
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