Living with chronic diseases can be an ongoing battle, and for many individuals, access to appropriate medications plays a vital role in managing their conditions. Unfortunately, navigating the world of health insurance can often be a challenging and frustrating experience. In this blog post, I want to share my personal journey of appealing CVS Caremark’s denial for prior authorization of insurance coverage for Mounjaro, a medication that has proved beneficial in treating my chronic diseases, including obesity, pre-diabetes, and PCOS with insulin resistance.

The Initial Success:

For ten months, I have been successfully taking Mounjaro, which has shown significant improvements in my health and overall well-being. The manufacturer of Mounjaro, Eli Lilly, initially offered a coupon that enabled all patients access to this new medication for a maximum out of pocket cost of $25/month, which I have utilized for the last ten months of treatment. That coupon expired 6/30/2023. Mounjaro has helped me to lose 45 lbs, lower my A1C, relieve some of my chronic knee pain and has enabled me to lead a more fulfilling life. The positive changes I have experienced were noticeable not only to me but also to my healthcare provider, who supports my continued use of the medication.

The Unexpected Denial:

My hopes for continued use of Mounjaro were crushed yesterday when I received an email notification from CVS Caremark stating that my appeal for prior authorization of insurance coverage for Mounjaro has been denied. The denial seems unfair, unfounded and confusing, given the clear benefits I have experienced during the past ten months. It has left me feeling frustrated, helpless, and concerned about the potential consequences of discontinuing the medication.

The Impact of the Denial:

The denial of insurance coverage for Mounjaro has far-reaching consequences for individuals like me who have come to rely on medication to manage my chronic diseases. Without access to the appropriate treatment, the weight may come back despite my efforts, and my A1C may climb to a new diagnosis of diabetes, leading to a decline in health and quality of life. In my case, the denial jeopardizes my ability to effectively manage obesity, pre-diabetes, and PCOS with insulin resistance, conditions that require ongoing care and attention.

The Appeals Process:

Following CVS Caremark’s denial of both Mounjaro and Ozempic (despite their own requirement of trial and failure of Ozempic or other formulary alternatives before they would approve Mounjaro) I delved into the appeals process, determined to fight for my right to receive the only medication I have found effective. The process involved gathering extensive information regarding my health history, multiple doctor’s appointments, and writing a detailed appeal letter on my own behalf (linked below), in addition to more of my doctor’s precious time spent filling out yet another request for coverage instead of spending time with his patients. I meticulously presented my case, highlighting the positive impact of Mounjaro on my well-being and the potential risks associated with discontinuing the treatment.

The Need for Advocacy and Support:

Throughout my journey, I have realized the importance of advocacy and support when faced with insurance denials. I await the official letter of denial with instructions for what my next step is. I believe I have the right to request an External Review, which I plan to do. Connecting with patient advocacy groups, seeking legal advice, and utilizing online resources will help me navigate the complex appeals process.  I am thankful for my online community for sharing their experiences and I will continue to seek guidance from individuals who have encountered similar challenges and hope to build my confidence and determination to fight for the medication I need. 

The denial of insurance coverage for Mounjaro by CVS Caremark has shed light on the arduous journey individuals face in accessing necessary medications for managing some chronic diseases, when our insurance providers and some medical professionals have not yet caught up with the latest science in treatment. While the road to appeal can be daunting, it is essential to persist and advocate for our health and well-being. Through sharing our stories, seeking support, and raising awareness about these challenges, we can strive for a system that prioritizes the needs of patients and ensures access to vital medications. 

I have decided to share my Prior Authorization Appeal Letter in hopes that it will either help someone else to write their own, or to shed light on my case and highlight all that CVS Caremark has chosen to ignore in their denial of coverage.

 At age 50, I am now in better shape than I was in my 30’s. Plus Size Plastic Surgery and weight loss from my own efforts in intuitive eating, increased activity, and treatment with Mounjaro is responsible for that.