Have you ever gone to the pharmacy only to find out your insurance doesn’t cover a medication that’s been ordered for you?  It can be an incredibly frustrating process. One way to prevent this is to contact your insurance plan first to see what prescription drugs are preferred.  

Your insurance may suggest a certain drug in a class of similar medications over others, which is valuable information to share with your healthcare team. If the ordered medication is not covered, there can be several reasons why — and you can appeal the decision. The more information you have, the better.   

 

  • Sometimes, there is a preferred brand (i.e., Humalog vs. Novolog) 
  • Insurance plans can change their formularies (preferred drugs), forcing people to switch medications 
  • Other times, insurance plans may require specific criteria to be met before a drug is prescribed (such as using the max dose of metformin and not meeting glycemic goals before approval of a GLP-1 receptor agonist) 

 

If the medication is expensive and there’s no generic version, ask if there is a co-pay card to help offset the price. Depending on the type, it can help offset the medication’s price and significantly lower your out-of-pocket cost. Keep in mind that these generally don’t work for people with government insurance plans like Medicaid or Medicare. 

 

What is prior authorization? 

It’s a cost-control process that requires insurance approval before you pick up a medication from the pharmacy. Even with prior authorization, a drug still may not get approved. Your need must be well documented and meet the insurance plan’s specific criteria for use. 

Having prior authorization is a common prerequisite for many medications. Your insurance company is looking for more information about drugs you’ve already tried — and maybe lab work, such as your most recent A1C.  

  

Write an appeal letter: here’s how 

Fortunately, if this happens, you and your healthcare team can take action by writing an appeal letter.  There are two types:

Internal appeals happen directly with the insurance plan and are usually done first.   

External appeals happen when internal appeals are rejected. In this case, you can request an external appeal. This means it’s sent to a third party for review, and the insurance company must follow the decision they reach.
 

If a drug is not approved,  

  • Your insurance plan must notify you in writing within 15 days and explain why.   
  • Then, you have up to 180 days to file an internal appeal.   
  • Medicare allows up to 120 days, and Medicaid plans are state-specific.
     

Depending on your healthcare plan, you may be required to submit specific forms. You’ll need to contact them to be sure.  

An appeal letter can be written by you or your healthcare provider. You’ll need to include your:

 

  • Full name  
  • Contact details 
  • Diagnosis and healthcare provider information 
  • Health insurance ID number 
  • Policy holder’s name (if it’s different from yours (i.e., a spouse or parent) 
  • What was denied, the date of the denial, and the stated reason for it 

 

Finally, you must communicate why you believe the medication should be covered. This is best done concisely and objectively. In other words, keep it short and to the point. 

 

Medications commonly denied with T1D: GLP-1s and insulins 

Unfortunately, many insurance plans will deny GLP-1 receptor agonists when they’re prescribed for a person living with T1D — again, even with prior authorization. That’s because GLP-1 drugs are not covered for use in T1D. Rather, they’re FDA-approved for use in people living with type 2 diabetes (T2D) and obesity. But there are exceptions. 

If a person is diagnosed with T1D and also has symptoms of T2D, such as insulin resistance, or lives with overweight or obesity, it’s crucial to provide this information. Moreover, when your healthcare provider documents this in your chart, it can be used as supportive information for why a GLP-1 drug should be covered.   

Listing the latest research about the benefits of GLP-1 use in type 1 diabetes can be helpful, too. More can be found here and here.  

Sometimes, people are forced to switch the brand of insulin they’re using because of an insurance formulary change. That said, if you’ve already tried the suggested insulin and had adverse effects, were allergic to it, or it didn’t work effectively to manage glucose levels, this information should be shared in an appeal letter.   

  

Are there other helpful resources? 

Yes, if you have a Medicare or Medicaid plan, the Consumer Assistance Program | CMS can help. Additionally, the National Association of Insurance Commissioners also offers a sample letter to request an internal appeal. Click on the links to learn more.

 

Try an AI tool to help format a letter 

ChatGPT and other AI tools can be used as a starting point and be tailored to your unique situation.  

If you’re unsure of how to start, tools like ChatGPT can help design a template. For example, I asked ChatGPT, “Can you write an appeal letter for semaglutide use in type 1 diabetes?” Here’s a snapshot of what was provided.  

 

Dear [Insurance Company Name] Appeals Department, 

I am writing to formally appeal the recent denial of coverage for semaglutide (Ozempic), which my endocrinologist, Dr. [Doctor’s Name], prescribed for the management of my type 1 diabetes. I understand that semaglutide is primarily approved for Type 2 diabetes; however, due to my specific medical circumstances, Dr. [Doctor’s Name] has determined that it is a necessary and appropriate addition to my treatment regimen.  

 

Medical rationale and necessity 

I have been managing type 1 diabetes for [number of years] years and, despite following a rigorous treatment plan, I continue to experience significant challenges, including [describe specific issues such as frequent hypoglycemia, extreme glycemic variability, difficulty achieving target HbA1c, or complications related to diabetes]. These ongoing issues not only pose serious risks to my health but also negatively impact my quality of life. 

After extensive evaluation and consideration of my medical history, Dr. [Doctor’s Name] believes that semaglutide could provide significant benefits by [explain expected benefits, such as improving time in range, reducing after-meal glucose levels, assisting in weight management, or stabilizing glucose levels].  

Although semaglutide is not traditionally used for type 1 diabetes, recent studies and clinical experiences have shown that GLP-1 receptor agonists like semaglutide may offer substantial benefits to certain patients with type 1 diabetes, particularly those who have not achieved optimal results with standard insulin therapy alone. (Add any supportive evidence, including information on published studies.) 

 

Request for reconsideration 

Given the challenges I face in managing type 1 diabetes and the potential benefits of semaglutide as identified by my healthcare provider, I respectfully request that you reconsider your decision to deny coverage for this medication.  

Enclosed, please find a letter of medical necessity from Dr. [Doctor’s Name], along with my medical records and any supporting literature that underscores the rationale for using semaglutide in my treatment. I am more than willing to provide any additional information or undergo further evaluation if required. 

Thank you for your consideration. 

Sincerely,
[Your Name] 

 

When should I hear back about my appeal letter? 

Once the letter is submitted, the insurance plan should notify you within 10 days of receiving the appeal. Then, they must reach a decision within 30 days.  

If it was denied, the plan should state why. If you disagree with the decision, you can write an external appeal.   

Be prepared. Even after an appeal, the answer may still be “no.” This is especially true if the drug is being used “off-label” or prescribed for a different purpose than approved by the FDA. This would mean that you would be paying out-of-pocket for the drug or finding another funding source. 

Reach out to your insurance company—by being proactive, you’ll find out if there’s a preferred drug they would rather you use. If your prescribed medication is denied, remember you have the right to advocate for yourself by writing an appeal letter. By using available resources, you’ll be one step closer to getting the treatments you need.