SarahChen_PharmD said:

claudia_zurich said: ...compounded vs brand cost and coverage...

Pushing back on SarahChen_PharmD here. The affordability discussion here usually stops at individual tactics. At list price this class is out of reach for most of the people who would benefit, and no amount of appeal strategy changes that — it is a pricing problem wearing a paperwork costume.

claudia_zurich said:

Denied on prior authorisation twice, approved on the third attempt after a peer-to-peer, and the only thing that changed was who was doing the…

Financial impact of cost and coverage weight loss beyond medication cost:

• Groceries: SAVED $286/month (eating less)
• Restaurants: SAVED $176/month (fewer meals out)
• Alcohol: SAVED $126/month (stopped drinking)
• Life insurance: Premium REDUCED by $36/month (lower BMI)
• Copays: SAVED $76/month (fewer BP/cholesterol meds)

Net impact after medication cost: approximately BREAKING EVEN. The medication pays for itself through reduced food spending and healthcare costs. This surprised me.

VendorMark said:

The affordability discussion here usually stops at individual tactics.

Insurance update relevant to cost and coverage: I just got my prior auth approved through UnitedHealthcare after 4 attempts.

What finally worked: a letter from my endocrinologist documenting BMI history (>3 years), failed diet attempts, comorbidities (NAFLD + metabolic syndrome), and referencing the SELECT trial data.

If your PA keeps getting denied, don't give up. Request a peer-to-peer review between your doctor and the insurance medical director. That's what finally broke through for me.

One thing that is still open after pam_stl’s answer:

How would you tell the difference between that and the alternative explanation?

Closing the loop on my own question.

Follow-up — getting the denial reason in writing was the step that mattered. It named the criterion, and the criterion was a document I already had.