My wife has been using Saxenda. She has type 2 diabetes and suffers from obesity. She has been using injection since on or about Sept 2018.
We tried to start consolidating our finances so my wife dropped her insurance and she came onto mine Jan 1st, 2021. Caremark was her PBM, Mine is Express Scripts.
So the doc sent an usual Saxenda Rx to Express Scripts and it needed prior auth. We tried to get prior auth with doctor involved but Express Scripts is saying my wife doesn’t meet their criteria for using this medicine. Denied. I tried to explain she is already taking it and showed proof but it didn’t matter. When we pressed them for what the criteria for use is they said something about needing a baseline weight but can’t tell us specifically or we will “game the system”.
How should I go about appealing for my wife?
submitted by /u/nynj2008
[link] [comments]
My wife has been using Saxenda. She has type 2 diabetes and suffers from obesity. She has been using injection since on or about Sept 2018. We tried to start consolidating our finances so my wife dropped her insurance and she came onto mine Jan 1st, 2021. Caremark was her PBM, Mine is Express Scripts. So the doc sent an usual Saxenda Rx to Express Scripts and it needed prior auth. We tried to get prior auth with doctor involved but Express Scripts is saying my wife doesn’t meet their criteria for using this medicine. Denied. I tried to explain she is already taking it and showed proof but it didn’t matter. When we pressed them for what the criteria for use is they said something about needing a baseline weight but can’t tell us specifically or we will “game the system”. How should I go about appealing for my wife?
submitted by /u/nynj2008 [link] [comments]Read Morer/HealthInsurance