Eight modules, two bonus modules, 18 letter templates, and the Letter Builder. Built on the plans’ own published criteria and the federal appeal rules. Lifetime updates.
It says the request “does not meet the plan’s clinical criteria,” and it does not say which criteria, or what would satisfy them, or who decided. You called and got one answer. You called again and got a different one. Your doctor’s office says they sent everything. Somewhere on page two there is a deadline you have not calculated.
Meanwhile the pharmacy quoted you $449 a month.
And underneath all of it is the question nobody will answer: is this worth fighting, or should I just pay?
Not all of them can. If yours is one that cannot, we would rather tell you that here, for free, than sell you a course that will not move it. Pick whichever line sounds most like the reason on your letter.
Most first appeals are a letter explaining how much the medication matters. That letter cannot be answered, so it gets denied.
What moves a file is different, and it is mechanical. Your plan has a written criteria document. It lists numbered requirements. Your denial named one of them. The appeal that works is the one that quotes that criterion back, attaches the document that satisfies it, and does the reviewer’s job for them in ninety seconds.
The plan’s own written criteria document. On a self-funded plan, asking for it is a right under the federal claims rules rather than a favor, and almost nobody uses it.
Quote the numbered criterion your denial cited, and attach the record that satisfies that exact requirement. Not a story about why the medication matters.
Where it goes, before the deadline, in a form that leaves you holding evidence you filed it. Then the follow-up call, two weeks later, with three specific asks.
That is the whole method. The Playbook is that method written out, with the letters already drafted and every deadline in one table.
Manufacturer, PBM, plan, pharmacy. Why your employer, not your insurer, is often the one who said no. Fully insured versus self-funded, and how to find out which you are in one phone call.
The 18-code taxonomy, the plan-type determination, the deadline computed and calendared, and the triage decision. Plus how to spot the denial that is not a denial at all, which is a claim-processing error and takes days rather than months to fix.
Four clean tracks so you read only yours. Every deadline, the expedited criteria, and external review explained as the leverage it actually is.
The document request, with the letters written. On a self-funded plan this is a right under the federal claims rules, not a favor, and almost nobody uses it.
Weight history, comorbidity documentation, prior therapy, and where to find proof you did not know you had. Plus the indication conversation with your prescriber, handled correctly.
The one-page ask that gets a yes, what belongs in a letter of medical necessity, and how to request and prepare a peer-to-peer review so your doctor does not take the call cold.
Letter anatomy, the Letter Builder, filing mechanics, proof of filing, and the follow-up scripts.
Second level, external review, Medicare’s higher rungs, the state insurance complaint, the employer escalation almost nobody makes, when to hire an attorney, and what to do if you lose.
The renewal denial that arrives after the medication works, why it usually applies the wrong criterion, and how to preempt it 90 days out.
Manufacturer direct pricing, savings cards and who they exclude, copay foundations and their eligibility trap, open enrollment strategy, and a clear-eyed look at where compounded products currently stand.
Reads your letter and gives you the structured read: what your plan decided, which of the four systems governs you, your deadline as a real date with days remaining, and an honest assessment of whether the case is winnable. It is free, and it stays free.
Drafts your appeal from your inputs and the correct template. One thing about it is worth stating plainly, because it is a design decision rather than a limitation: it will not invent a clinical fact.
If you have not given it a diagnosis, a date, or a prior medication trial, it writes a visible bracket in the draft rather than a plausible guess, and it will refuse if you ask it to make something up.
It also shows you a table listing every clinical claim in your letter next to the input that authorized it. That is not caution for its own sake. An appeal containing something your records do not support is insurance fraud, and it is also the fastest way to lose a case you could have won.
Every rule in this course is cited to healthcare.gov, the eCFR, CMS, KFF, or a plan’s own published criteria, with the date we verified it. We read nine payer criteria documents in full to build it. Every page carries a last-updated date. There is a public changelog.
A win rate. We do not have audited outcome data, and any number we printed would be marketing rather than evidence. When we have real customer results and their permission, we will publish them unedited, and we will say plainly that individual results vary.
| What you are comparing | Cost |
|---|---|
| One month of Zepbound self-pay, higher doses (verified June 2026) | $449 |
| One month of Wegovy self-pay (verified June 2026) | $349 |
| Twelve months at $349 | $4,188 |
| A patient advocate, four hours at $150 | $600 |
| Claimable, one AI appeal letter, per case | ~$50 |
| The Denial Playbook: GLP-1 Edition | $99 |
One month of what you are already paying covers this three times over. If it moves your coverage for a year, it paid for itself forty times.
If you do the work and it does not help, we refund you in full.
“Do the work” means one thing: you ran your letter through the decoder and completed the Module 2 triage worksheet. Send it, or just tell us your triage result, and ask.
We will not ask whether you won. We will not ask you to prove you filed anything. And we will not refund based on outcomes in either direction, because tying a refund to whether an appeal succeeded would be a promise about results that nobody can honestly make.
This is a course. You do the filing, under your own name. If you want done-for-you, hire a patient advocate; expect $100 to $250 an hour, and it is often money well spent.
We will refuse, in the course and in the tools.
Bonus Module 2 covers that, but you do not need a $99 course for it. Go to the manufacturer’s site and check the current price. Really.
Run it through the free decoder. You may find your answer there and not need this at all.
Nobody can sell you that. Anyone who does is lying to you.
Run the thirty-second check above. Your appeal probably will not win, the course says so directly, and we would rather you knew that before you paid rather than after.
Some free tools are genuinely good. Counterforce Health is a nonprofit and it is free. Claimable runs about $50 a case. Both will produce you a letter. What they do not do is tell you which of four systems governs you, get you the plan’s own criteria document, prepare your prescriber, handle the renewal denial a year from now, or tell you when your case will not win. If a letter is all you need, use the free one. We mean that.
No, but read this carefully. Your appeal probably will not win, and the course says so directly. What the course gives you is the employer escalation (your employer wrote that exclusion, not your insurer, and they revisit it every year), the indication conversation with your prescriber, open enrollment strategy, and the full assistance landscape. If that is not worth $99 to you, that is a reasonable call. The free decoder will still tell you the truth about your case.
The Letter Builder drafts it from your inputs and you review, complete, sign, and file it. We do not file anything and we do not represent you.
No. It is consumer education about a coverage process. Clinical questions go to your prescriber, and the course says so every time one comes up. Where a situation genuinely needs a lawyer, the course tells you that and names the type.
Yes, and Medicare has its own track in Module 3 with its own deadlines and vocabulary. It also covers the Medicare GLP-1 Bridge, which runs through December 31, 2027, has a $50 copay, does not require a Part D denial first, and has no appeals process at all. Most people have not heard of it, and its criteria are measured at the time you started therapy rather than today, which matters a great deal if you have already lost weight.
Module 8 is the escalation ladder: second level, external review by an independent organization whose decision binds the plan, the state insurance complaint, and the employer route. Most people stop after one denial. The ladder goes further than that.
Start with the free decoder right now for the date and your route, then Modules 2, 3 and 7. The rest can wait. If your prescriber’s office is the bottleneck, Module 6 is the one that unblocks it fastest.
It helps enormously and Module 6 is about making it easy for them to say yes. On Medicare Part D exception requests the prescriber’s supporting statement is genuinely required. On most other tracks you can file yourself with records attached.
Lifetime access includes updates. When a formulary moves or a rule changes, the course changes. There is a public changelog so you can see it happening. This category has changed at least four times in the past year, which is exactly why that promise is worth something.
No. It is processed and discarded. We do not train on it. The privacy policy says the same thing in more words.
Yes, 60 days, on the terms above. It is a real policy, not a hurdle.
There is a hardship page with free access, no documentation required, and we approve by default. The decoder and Module 0 are free and are not a teaser. Use them.
Because almost everyone does. Fewer than 1 in 100 denied claims is ever appealed. That is the single most important number in this entire category, and it is not a statement about how hard appeals are. It is a statement about how few people try.
You have a deadline, and it is a real date, and it is closer than you think.
60-day refund · Hardship access here · The decoder costs nothing and will tell you whether you have a case worth fighting.