Hacking the Insurance Blockade: How to Get Your Meds Approved Faster

Pharmacy Benefit Managers (PBM) deny meds too often. Let's discuss this

If you’ve ever been told “we need to wait for a prior authorization” before you can get your medication, you already know how frustrating it can be. Days (or even weeks) of back-and-forth between the clinic, your insurance company, and the pharmacy — just to find out your medication wasn’t even covered in the first place.

Let’s fix that.

Here’s how you can cut through the red tape and take control of your prescription process — especially if you’re trying to get access to medications like GLP-1s (Ozempic, Wegovy, Mounjaro, etc.).

🚧 What’s Really Blocking Your Prescription?

Most insurance plans don’t make prescription decisions directly. They use a Pharmacy Benefit Manager (PBM) — a third-party company that decides:

• What medications are covered

• Whether a prior authorization is needed

• What alternatives they prefer (aka their “formulary”)

PBMs are like gatekeepers. If you don’t know who your PBM is, you’re stuck guessing what’s covered — and your doctor is too.

💡 Step 1: Find Out Who Your PBM Is

You can usually find your PBM by:

• Looking on the back of your insurance card — it may list your PBM (like CVS Caremark, Express Scripts, or OptumRx).

• Calling the Member Services number on your insurance card and asking:

“Who manages my pharmacy benefits, and how do I access my PBM account?”

🔐 Step 2: Log Into Your PBM Account

Once you know your PBM, go to their website (or app), and log in or create an account.

Inside your PBM portal, you can:

• View your pharmacy benefits

• See which medications are covered and potentially how much the monthly charge will be for your medications.

• Find out if a prior authorization is required

• Look for lower-cost or preferred alternatives

  
  

💊 Step 3: Check Coverage Before You Fill the Prescription

Before your physician or non-physician provider writes the script, search for the medication you’re hoping to take. This is especially important for drugs that often require prior authorization — like GLP-1 medications used for diabetes or weight management.

Here are common GLP-1s to look up:

• Ozempic

• Wegovy

• Mounjaro

• Trulicity

• Saxenda

• Victoza

  
  

Why this matters: If your PBM doesn’t cover the medication, or if they require a prior authorization, you’ll know before your doctor sends it to the pharmacy — saving you time and frustration.

📣 Step 4: Tell Your Clinic What You Found

Once you’ve confirmed your coverage, contact your care team with this info:

• The name of your PBM

• Whether the medication is covered

• Whether a prior authorization is required

Big Trees MD can’t begin the authorization process effectively or send in the prescription until we know this!

🧠 Why This Is So Important

Every time a prior authorization is submitted for a drug your plan never covers, it delays care and wastes everyone's time — especially yours.

When you check coverage first, we can:

• Skip unnecessary paperwork

• Talk about cash-pay options sooner (if needed)

• Find faster alternatives

• Get you treated faster

  
  

✅ TL;DR – The Fast Track to Your Meds

1. Find out who your PBM is (look at your card or call insurance).

2. Log in to your PBM account online.

3. Search for the medication to check coverage.

4. Send the results to your care team before a prescription is sent.

No more waiting in the dark. No more prescriptions that go nowhere.

Just a smarter, faster way to get what you need.

Let’s hack the insurance blockade — together.

After all, insurance is NOT healthcare.