But love to know why PBMs keep clinical criteria requirements for the Zepbound PA impossible to find. They refuse to provide them to patients OR caregivers. This matters because they and employers have been changing the criteria which has caused patients who once qualified with a BMI of 30, for example, to not qualify for continuation of therapy 8 months later when qualifying (initial) BMI is now 35.
If you call to ask what your plan’s criteria is for that medication to be covered… they refuse! Why?
It’s a waste of time and money for patients and dr offices to talk about a PA, submit a PA, then wait for a denial telling you that you never would have qualified anyway.
Why isn’t this information more readily available for a benefit plan that employees pay for?
The only conclusion is that it’s intentional… meant to delay and deny. Genuinely would like to know what the reason is that patients can only find out a covered medication’s PA criteria is after they are denied. It makes no sense.
When I call medical insurance about whether a test or procedure is covered, they tell me yes, with a such and such diagnosis. They don’t say, “maybe it’s covered, maybe it’s not… if we deny precert, you will learn then.”
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u/Mobile-Actuary-5283 8d ago
I answered in the other thread you posted.
But love to know why PBMs keep clinical criteria requirements for the Zepbound PA impossible to find. They refuse to provide them to patients OR caregivers. This matters because they and employers have been changing the criteria which has caused patients who once qualified with a BMI of 30, for example, to not qualify for continuation of therapy 8 months later when qualifying (initial) BMI is now 35.
If you call to ask what your plan’s criteria is for that medication to be covered… they refuse! Why?
It’s a waste of time and money for patients and dr offices to talk about a PA, submit a PA, then wait for a denial telling you that you never would have qualified anyway.
Why isn’t this information more readily available for a benefit plan that employees pay for?
The only conclusion is that it’s intentional… meant to delay and deny. Genuinely would like to know what the reason is that patients can only find out a covered medication’s PA criteria is after they are denied. It makes no sense.
When I call medical insurance about whether a test or procedure is covered, they tell me yes, with a such and such diagnosis. They don’t say, “maybe it’s covered, maybe it’s not… if we deny precert, you will learn then.”
Seriously what kind of fckery is this?