Short answer first, then the reasoning. Denials are usually procedural rather than clinical, and the order that works reflects that. Get the denial reason in writing, because it names the criterion you failed. Then supply the documentation that criterion asks for — usually documented BMI with a comorbidity, or a failed prior therapy. Then appeal, and ask for a peer-to-peer review, because a prescriber talking to a reviewing clinician resolves a large fraction of denials that written appeals do not. Manufacturer copay assistance is separate and applies mainly to commercial insurance, and patient assistance programmes are means-tested rather than a discount.

Dr.BariatricHTX said:

Denials are usually procedural rather than clinical, and the order that works reflects that.

Dr.BariatricHTX has the substance of this right. The condition it depends on is worth stating. The manufacturing argument is the underrated one. Peptide synthesis capacity has been the binding constraint on this entire class, and a small molecule is made in ordinary chemical plants. If it holds up in phase 3, the supply and price picture changes more than the efficacy picture does.

amy_econ_NJ said:

I have been following the oral non-peptide data since phase 2 and I am trying to work out how much of the enthusiasm here is about efficacy and how…

Agreed, and coverage criteria are plan-specific rather than insurer-specific. Two people with the same insurer and different employers have different rules, which is why "my insurer covers it" is not transferable information.

Adding the clinical framing, because it changes how the question reads. If two explanations both fit, the useful question is which one predicts something the other does not. That is answerable; arguing about which sounds more plausible is not.