Coverage in the US: a map of the usual obstacles — setting out what I have, and where I think it stops being reliable.
Trying to establish the boundary conditions on coverage. The general claim is fine; I want to know where it stops holding, because that is where I am operating.
Three edge cases below, in increasing order of how far outside the usual range they sit.
United States: FDA licenses compounds. Prescribing and pharmacy practice are state-regulated. Compounds are prescription-only. Coverage is decided by individual plans, not nationally.
Worth checking against a second source before it gets quoted onward.
Cost comparisons should state whether they include the device and the dispensing fee, because those differ between routes and between states.
On coverage, the part that usually goes wrong is that the question is asked as though it has one answer. It has a range, and the width of the range is the interesting bit.
If you can post the two or three numbers you are working from, several people here will check the arithmetic rather than argue about the conclusion.
Confirming post #7 from a second method, which matters more than confirming it from a second person.
I would rather this thread reach "we do not know" about coverage than reach a confident answer that nobody can support when asked.
Appeals succeed more often than people expect when they answer the stated criterion point by point and include nothing else.
Adding the measurement that post #10 says would settle it.
Nobody has said the unglamorous part of coverage yet, so: most of the variation is explained by things that are boring to write about and easy to check.
My experience of coverage contradicts the reply above. I am posting it as a data point rather than as a refutation, because one person's experience is exactly that.
Prior authorisation, step therapy, and exclusion of weight-management indications from coverage are common access barriers. The denial letter tells you which barrier you are facing.
The interesting part of this is the exception, and I do not understand the exception.
Answering the coverage question as asked, then the question I think is meant. As asked: yes, with the qualification below. As meant: it depends on how the first measurement was taken.
The arithmetic in post #12 is right; the assumption feeding it is the part to check.
Coverage is well covered in the tag pages, and the older discussions are better than the recent ones because they were argued out properly. Worth twenty minutes before adding to this one.
Answering the question post #14 raises rather than the one it answers.
Anyone reporting an outcome should give the stated reason rather than the verdict. The reason is the part somebody else can use.
Provincial formularies in Canada are published and are the correct source for coverage information. Coverage for weight management is less common than for diabetes.
It is one reading of the data and not the only reasonable one.
The confident answers on coverage and the well-sourced answers are not the same answers, which is the most useful thing I have learned reading this category.
Coverage decisions are made by individual payers and vary within the same jurisdiction. A denial from one says nothing about another.
It is worth stating the boring hypothesis before the interesting one.
Answering the question post #19 raises rather than the one it answers.
Canada: Health Canada licenses compounds. Prescribing is provincial. Compounds are prescription-only. Coverage varies between public and private insurance.
Second this, and I would have said it less carefully.
Post #22 is the version of this I will quote in future. One addition.
A note on how coverage gets discussed rather than on coverage itself: the confident posts get the replies and the careful ones get ignored, and the careful ones have been right more often.
Answering the question post #24 raises rather than the one it answers.
Date every claim in this subcategory. Positions here have moved repeatedly and old posts are read as current.
The arithmetic in post #24 is right; the assumption feeding it is the part to check.
I read the earlier replies on coverage twice before writing this, because I had assumed the opposite and wanted to be sure I was disagreeing with what was said rather than what I expected.
The honest answer on coverage is that it depends, and the useful part is the list of what it depends on. Four items, in rough order of how much they matter.
Most people get the first two right and then argue about the fourth.
Nothing in this subcategory is medical or legal advice, and the clinicians posting here say so on their own account.
Old habit: I write down the expected answer before I calculate it.
Say which country and which state or province. Regulatory position, availability and practical route can all differ within the same continent and frequently do.