[Updated May 20, 2024] If you’ve recently been denied coverage for Mounjaro by your insurance provider, you have the legal right to appeal the decision. The process of appealing may seem daunting, but don’t worry - we’re here to walk you through it. This article will explain step-by-step how to appeal an insurance denial for Mounjaro.
New to appeals?
If your insurance denied coverage for Mounjaro, you have the legal right to ask your insurance to reconsider the coverage denial by sending an ‘appeal’. It almost always makes sense to appeal, but many people don’t. A study from September 2023 found that 69% of people who were denied coverage by their insurance didn’t know they could appeal, and 85% of people never tried to appeal.
An appeal is a formal request to your health insurance company to reevaluate its decision to deny coverage for a medical therapy or service. When insurance first denies coverage for Mounjaro, the denial decision is almost always made by a computer. In the appeal process, a real person has to review your coverage request and make a decision.
You can send an appeal within six months of the denial notice. When insurance denies coverage, they are obligated to send you an explanation about why they denied coverage and instructions on how and where to send an appeal. Mail and fax are two common ways to submit an appeal. Visit healthcare.gov for general information on appeals.
Honest Care has you covered with our step-by-step guide for Mounjaro appeals. Feel free to skip the sections of this guide that are most relevant to you
Need Help Appealing? Explore Honest Care's GLP-1 appeal service.
Key Takeaway: You have the legal right to fight for the treatment you deserve, and appeals often succeed. If starting or continuing treatment on Mounjaro is important to you, then appealing is worth the effort.
Before digging into the details of how to appeal, you might be asking whether it makes sense to appeal based on your unique circumstances. In short, it’s almost always worth appealing. Here is why:
Key Takeaway: Identifying the specific cause of denial will help you form an effective appeal strategy. Need help navigating your insurance denial? Try Honest Care appeal services.
Depending on your insurance provider and the parameters of your insurance formulary (or the drugs and procedures covered by your insurance), there are multiple reasons Mounjaro could be denied for coverage. Below is a list of the most common insurance denial reasons for Mounjaro:
Key Takeaway: Including supporting evidence helps justify your request for coverage summarized in your appeal. Need help? Honest Care can help you gather your Mounjaro supporting evidence.
Key Takeaway: An effective appeal letter addresses your reason for Mounjaro denial and summarizes your health history, past medications you have tried, and your current and past lifestyle modification attempts through diet and exercise. Need help? Honest Care can write your appeal letter.
Because each person has unique circumstances, there isn’t an exact science to writing an effective Mounjaro appeal letter. That said, there are best practices or “ingredients” to consider to write an effective letter. Here is what we recommend:
Your insurance will specify the exact details on how to submit your appeal. Below are a few important questions to answer before you submit your appeal:
We help patients fight insurance coverage denials so they can get access to the medications and treatments they deserve. We currently specialize in insurance coverage denials for Ozempic, Mounjaro, Wegovy and Zepbound.
If you are denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, Honest Care can help fight your denial by submitting an ‘appeal’ to your insurance. An appeal is a formal request to your health insurance company to overturn their denial and grant coverage on your behalf. An appeal generally consists of a formal letter, addressed to your insurance, explaining why a medication should be covered on your behalf and why your insurance’s initial denial should be overturned.
You have the right to appeal to your insurance’s coverage denial. Honest Care simplifies the appeals process by writing an appeal letter and supporting documents on your behalf making your best arguments for medication coverage, following your completion of our proprietary GLP-1 denial assessment.
If your insurance denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, you have the legal right to ask your insurance to reconsider the coverage denial by sending an ‘appeal’. Unfortunately coverage denials too often go unchallenged. A study from September 2023 found that 69% of people who were denied coverage by their insurance didn’t know they could appeal, and 85% of people never tried to appeal.
We believe it always makes sense to appeal. Here is why:
Appeals work: According to a study analyzing data from several U.S. states, patients who appealed directly to their insurance provider (an internal appeal) experienced a success rate between 39-59%.
Denials are often issued by mistake: A computer almost always makes the initial decision to deny medication coverage. This results in denials that don’t actually consider your personal health situation or denials made by mistake. In the case of Ozempic, Mounjaro, Wegovy and Zepbound, incorrectly entered information about your BMI, labs including A1c, your health conditions and diagnoses, your medication history and current medication use can all lead to an automatic denial. When you appeal, your information is reviewed by a real person.
Doctors review appeals, not computers: Having a doctor consider your unique circumstances makes submitting an appeal a powerful process for overturning denials getting covered.
You deserve the best care: You have the legal right to fight the treatment you need. As a part of the Affordable Care Act, all health insurance plans are required to allow their members to appeal their coverage decisions. This spans all insurance coverage - whether you are insured through your employer, purchased an insurance plan through your state marketplace, or are insured through a government program like Medicare or Medicaid.
We currently offer appeal services for Ozempic, Mounjaro, Wegovy and Zepbound. After purchasing Honest Care and completing your online denial assessment, you can expect to receive your appeal letter within 2 business days.
1. Online denial assessment: Complete the online assessment at your convenience that gather all the necessary appeal evidence for your insurance. The assessment reviews your medication history, including any GLP-1s, weight loss or diabetes medications you have taken, your health conditions and diagnoses, your past weight loss, diet and exercise attempts, and details on your insurance coverage and denial.
2. Case evaluation & appeal strategy: One of our dedicated appeal specialist will review your assessment and insurance denial and identify your best appeal arguments for coverage. This will include an evaluation of your medication history, medical diagnoses, weight loss attempts and clinical research studies that strength your appeal case.
3. Appeal letter & supporting documents: Your assigned appeal writer will compose a professional appeal letter addressing your denial reason and detailing your case for coverage. We’ll create a supporting evidence report that further justifies your appeal letter, to send your insurance along with your appeal.
4. Specialist Consultation & Support: After you receive and review your appeal letter & evidence, your dedicated appeal specialist will be available to answer your questions. They will be available to make updates to your appeal, if required. You will also have the option to schedule a phone or video call at a time of your convenience to you speak to your dedicated appeal specialist.
5. Send your appeal: You can submit your appeal yourself or have your doctor submit your appeal on your behalf. Most insurance companies accept appeals by mail or fax. Instructions on how to submitted appeal will be included within the written explanation on why you initially denied medication coverage, sent at the time at you were denied.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments, because access to great healthcare is a human right.
Our Money Back Guarantee is designed to help you overcome any obstacles or questions you have about appeals and exercise your legal right to fight for the coverage you deserve. Obstacles such as -"What if I appeal and still don’t win coverage?", "I don’t know how to appeal" and “I’m not sure what to say in my appeal.”
We offer a Money Back Guarantee for all our customers. If you're not satisfied with our service, you can request a refund no questions asked. To be eligible, contact support@findhonestcare.com with your order details and the reason for dissatisfaction. Refunds are processed to the original payment method within 5 to 10 business days.
Your appeal packet will include two main documents: 1) Your appeal letter and 2) Your supporting evidence. You can review a sample Honest Care appeal that includes an abridged appeal letter and evidence for demonstration.
Working with your regular doctor can increase your chance of insurance coverage in several ways, including:
Yes - your Honest Care Report can be submitted to any doctor, including doctors working with online, telehealth-based GLP-1 clinics. Taking the Honest Care Assessment before engaging with a telehealth services presents several advantages, including helping you save money.
By using Honest Care before engaging with a telehealth company, you’ll find out how likely you are to get a GLP-1 prescription and will receive guidance on any recommended steps to take before your GLP-1 appointment. This can save you money by avoiding paying subscription fees until you’re fully prepared for your telehealth appointment.
There are nearly 10 GLP-1 medications available in the United States. Currently three of those medications, Zepbound®, Wegovy® and Saxenda®, are FDA-indicated for weight-loss assistance. The FDA indicates that people with a BMI ≥ 30 kg/m2 OR people with a BMI ≥ 27 kg/m2 who have been diagnosed with at least 1 weight-related condition are eligible for GLP-1s.
All other GLP-1 medications, including Ozempic® and Mounjaro®, are currently FDA-indicated for people diagnosed with Type 2 diabetes.
While FDA-guidelines are critical for understanding GLP-1 eligibility, there are a number of other factors to consider for determining GLP-1 eligibility.
Additional eligibility criteria that Honest Care takes into account include:
Prior Authorization (PA) is a process run by insurance plans to determine how necessary a medication is. Most insurance plans require Prior Authorization (PA) before approving coverage for GLP-1s.
After your GLP-1 prescription is written, your insurance plan will notify your doctor if a PA is required and ask your doctor for additional documentation on why your medication is necessary.
If a PA is required, your insurance plan will ask your doctor to submit detailed information on your diet and exercise history, your past weight loss attempts, weight loss medications you previously tried, and any unique challenges that you face that make a GLP-1 medically necessary.
The Honest Care Report includes evidence requested by most insurance plans and can be submitted to your insurance during the PA process. During your appointment, your doctor can attach your Honest Care Report to your health record so it is submitted as supporting evidence to your insurance if Prior Authorization is required.
