What to Do If Your Plan Denies Coverage

Step one: read the reason

Denials cite a reason — not medically necessary, non-formulary, step therapy required, or plan exclusion. Each has a different remedy, so identifying the exact wording matters.

Appeals and alternatives

Your clinician can submit additional documentation or request a formulary exception. If the plan excludes the benefit entirely, appeals rarely succeed and the practical options are a covered alternative medication or self-pay.

Maryland residents may also have external review rights through the Maryland Insurance Administration for certain medical-necessity denials.

How FRDC handles this

Choose Insurance on the new patient intake and enter your carrier. Our team verifies your benefits before your first visit and tells you what you will owe. If your plan is one we are not contracted with, the intake form tells you immediately and shows you the self-pay path instead of letting you find out later.

Self-pay pricing is published: $150/month clinic fee (once every 90 days at maximum Mounjaro dose), Phentermine + B12 $84/month, Mounjaro or Zepbound $399–499/month, Ozempic or Wegovy $199–399/month, B12 injections $15 each. Your information is used only to schedule and verify coverage.

Results framing

Your clinician sets your goals — many plans target 10–16 lbs/month with strict protein protocols; individual results vary.

Medication and dosing are always determined by your clinician after evaluation.

Frequently asked questions

How long do I have to appeal?

Deadlines are stated in your denial letter and are strict. Act quickly.

Can FRDC help with the appeal?

Your clinician can supply clinical documentation supporting the request.

What does self-pay cost?

$150/month clinic fee plus published medication pricing.