Getting my GLP-1 medication approved by my insurance was not as simple as getting a prescription. Before my insurance company would approve the medication, I had to go through a prior authorization process.
What is Prior Authorization?
Prior authorization is a process insurance companies use to decide whether they will cover certain medications. My doctor had to send information about me and all my co-morbidities showing why the GLP-1 medication was medically necessary before insurance would pay for it.
What My Insurance Company Required
For prior authorization, my insurance wanted documentation showing why I needed a GLP-1 medication. Since I was already being treated for Type 2 diabetes (DM2) and high blood pressure (HTN). My doctor was able to document those current chronic conditions along with my unhealthy BMI. I had everything but my sleep study.
Before my doctor would submit the prior authorization, she wanted me to complete a sleep study. Not only did the sleep study confirm what I already knew, it opened a whole other can of worms. For years, I already knew that I snored badly and according to my family I would stop breathing and sit up choking and gasping and then lay back down and fall back to sleep.
What I Already Knew -vs – What the Sleep Study Said
I already knew I had sleep apnea, but I never had a formal diagnosis from a doctor. What the Sleep Study said is that I had severe sleep apnea and possible AFib. With this new diagnosis I had to start using a CPAP machine and see a cardiologist while I waited for my GLP-1 approval.
Like I mentioned before, I knew that I had undiagnosed sleep apnea; but I didn’t know that it was severe. No wonder I could not work a full shift or drive 20 minutes and not doze off. Therefore, finding out that I had severe sleep apnea was a little scary, especially when they mentioned possible AFib. What started out as something that I needed to complete before my prior authorization could be turned in. This actually turned out to be something much more important for my overall health. I went into the sleep study thinking it was another hoop for my insurance, but I came out realizing there were health issues I needed to take seriously.
Waiting for My GLP-1 Approval
After completing my sleep study, it took about a week for the nurse to call me back. She asked, “which DME company I wanted to get my CPAP machine from, what cardiologist I wanted to use, and what pharmacy I wanted to fill my medication”.
Also, while on the phone with the nurse, she explained that there are several GLP-1 medications available. She also explained that my doctor wanted me to use Mounjaro, because it is better suited for someone like me and my different medical conditions.
Getting Ready to Start Mounjaro
Once all appointments were made and my medication was called into my pharmacy, I immediately went to pick it up, but to my surprise and disappointment, it was not in stock. After waiting several days, I finally got a text from the pharmacy that my order was filled and ready for pick-up.
Once at the cash register, I was prepared to have a copay. But instead, I had a zero balance. My insurance company had covered the entire $1,200 I could not believe it as I was putting away my FSA card.
What I Learned From the Prior Authorization Process
What I learned from the prior authorization process is that I have developed patience and discipline. The younger me would have said forget it and walk away without trying, no matter how aggravating, frustrating, and tedious things became, I continued to do as I was asked.
Going through the prior authorization process taught me that getting approved for a GLP-1 medication can take patience, paperwork, and a little persistence. There were extra steps I wasn’t expecting, including the sleep study, but I kept going. When the approval finally came through, it felt like one more step forward in my journey. I know this is only the beginning, and I’m looking forward to sharing what happens next—the good, the frustrating, and everything in between—as I continue growing beyond the scale. If you’re new here, you can also read how my journey started in Starting Over at 59: My Journey Beyond the Scale
