[Updated May 30, 2024] How to get prior authorization for Wegovy and fight prior authorization denials for Wegovy
ⓘ Denied prior authorization for Wegovy? Know your appeal options in 3 minutes with our free appeal assessment.
Prior authorization (PA) is almost always required for insurance to cover Wegovy (semaglutide). Understanding those requirements in advance is a key step to getting your prior authorization for Wegovy approved. The easiest way to do this is to call your insurance, share your Member ID and ask whether Wegovy is on your plan’s drug formulary and what the specific prior authorization criteria are. If you take this step, it is worth asking for their Zepbound and Saxenda prior authorization criteria as well.
While the exact prior authorization requirements are different depending on your insurance and pharmacy benefits manager (PBM), such as OptumRx, United HealthCare, CVS Caremark, Express Scripts, Cigna, Aetna, Blue Cross Blue Shield (BCBS), prior authorization requests for Mounjaro always require similar categories of information.
Prior authorization decisions can take anywhere from at little as a few minutes or as much as 30 days. You may be able to check the status of your prior authorization by logging into your insurance’s online patient portal - if not, you can call your insurance.
An effective appeal can help get your denial overturned. A study from the US Government Accountability Office found that 39-59% of internal insurance appeals were successful.
All Wegovy prior authorization requests include a section for ‘Clinical Criteria’, which might also be referred to as Diagnosis or Medical Information. The goal of this information is to prove that you meet the clinical (medical) necessity requirements for Wegovy. The standard information requested includes:
The primary diagnosis code reported within your prior authorization request indicates the specific health diagnosis for which Wegovy is being prescribed to treat, described by an ICD-10 code.
Wegovy is FDA-approved as a treatment for 1) obesity or 2) to reduce the risk of major cardiovascular events in adults with cardiovascular disease who are overweight or obese.
If you do not have a history of cardiovascular disease, stroke or heart attack, then you are likely being prescribed Wegovy for the treatment of obesity. In this case, Wegovy is indicated an an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with a BMI of 30 or greater (obesity) or 27 or greater (overweight) with at least one weight-related comobid condition. This means the ICD-10 code that best describes your obesity diagnosis should be included here. Below are the common reported ICD-10 codes for obesity:
If you have a history of cardiovascular disease and/or are at risk of a major cardiovascular event, such as heart attack or stroke, then the diagnosis code used in your prior authorization for Wegovy should best reflect your cardiovascular disease. Examples might include:
In this section, any comorbid diagnoses that have been caused by or are related to obesity should be reported. Including accurate information is especially important if your BMI is above 27 (overweight), but not above 30. Below are some common weight-related comorbid diagnoses (and the corresponding ICD-10)
In this section, any weight loss medications you have tried prior should be reported, such a Contrave, Qsymia, Phentermine, Orlistat or Saxenda. Insurance may deny prior authorization for Wegovy if you haven’t tried cheaper medications options first, which is a policy commonly referred to as ‘step therapy’.
Prior authorizations for Wegovy frequently ask questions to confirm that you have participated in a weight loss program within the last 12 months, and that you were not able to lose weight while enrolled in the program.
Wegovy is indicated an an adjunct to a reduced-calorie diet and increased physical activity for chronic weight managements, which means thats prior authorization for Wegovy frequently asks for confirmation that you are currently on a calorie-restricted diet and are physically active.
All Wegovy prior authorization requests include a ‘Drug Information’ section asking for details on your Wegovy prescription. Here is what you can expect to be included and example responses for an initial prescription.
Wegovy comes in five different dosing strengths. When starting on Wegovy, the initial prescribed dose is 0.25 mg. After 4 weeks on 0.5 mg, your doctor will increase your dose to 0.5 mg. Below are a full list of Wegovy dosages:
The standard maintenance doses for Wegovy are 1.7 mg and 2.4 mg. 3-month prescriptions can be written for both doses.
Need help with appeals? Honest Care can write your appeal letter.
If your prior authorization request for Wegovy is denied, it’s critical to understand why. If you didn’t receive a written explanation or letter from your insurance explaining the denial, you can call your insurance and ask. Prior authorization for Wegovy can be denied for many reasons. If your request is denied, you have the right to appeal.
This means that Wegovy is not on the list of the medications covered by your insurance. Your plan may have “preferred” GLP-1s that they request you take instead of Wegovy, such as Saxenda. If Wegovy is not on your plan’s medication list, you can specifically ask for a “formulary exception” within your appeal.
If your insurance thinks you don’t meet the medical requirements for Wegovy, such as the BMI or health condition criteria, they will argue that approving coverage is not “medical necessary”. This can be resolved by detailing why your medical history makes Wegovy necessary within your appeal.
Many insurance plan’s ask that patients try alternative weight loss treatments before Wegovy, such as Contrave, Phentermine, Orlistat, Qsymia or Saxenda. If you have already tried one of these medications, your insurance may not know it. There may also be medical reasons why these medications are not safe for you and there is substantial research showing that Wegovy is a more effective medication than these alternative reasons. A combination of these arguments can be summarized in your appeal. Read our guide on Step Therapy Denials.
If you were denied coverage for failure to participate in a weight loss program, your best bet here is going to be to gather as much information as you can regarding your previous weight loss attempts. With this requirement, many insurance providers prefer participation in a paid, supervised plan such as Weight Watchers, Noom, or Jenny Craig. With that being said, you should still compile as much evidence as you can surrounding particular diets you’ve tried, gym memberships and personal training sessions, and any exercise activity you’ve tried or currently utilize. Try your best to list starting and ending dates as well as outcome of the program. Some insurance providers require you to have tried a program for a duration of 3-6 months, and to have “failed” these programs, meaning you did not lose a set amount of weight in a set amount of time (usually something like 1 lb per week). Be sure you’re aware of the requirements of your plan so you can directly address them.
There is a chance that Wegovy was automatically denied because your insurance doesn’t cover weight loss medications as a category. You can appeal even if this is your insurance’s official policy. Insurance makes coverage decisions based on what will save the most money. Within your appeal, you can focus on how covering Wegovy now will save your insurance plan later. Read our guide on Weight Loss Plan Exclusion Denials.
ⓘ Denied prior authorization for Wegovy? Read our steps to appeal a Wegovy coverage denial.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments, because access to great healthcare is a human right.
Insurance companies purposely make this process convoluted and difficult to understand in order to deter decision challenges and protect their bottom line. That’s where we come in. We’re bridging the gap between insured individuals and their access to needed medications by creating a free customized insurance appeal letter. We’ll do all the hard work for you - you just need to include a few small edits, then you can send your appeal letter to your insurance provider through their outlined appeal process.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments we’ve made generating a strong appeal letter free.
We also offer paid services to access our team of GLP-1 experts. If you are not satisfied with our team's services, email our support team at support@findhonestcare.com and we will be happy to remedy any issues. You can also request a refund within 60 days of purchase of our services so long as your appeal hasn't been submitted to your insurance. Once our appeal packet has been submitted to your insurance, we will no longer issue refunds. Refunds are processed to the original payment method within 5 to 10 business days.
We help patients fight insurance coverage denials so they can get access to the medications and treatments they deserve. We currently specialize in insurance coverage denials for Ozempic, Mounjaro, Wegovy and Zepbound.
If you are denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, Honest Care can help fight your denial by submitting an ‘appeal’ to your insurance. An appeal is a formal request to your health insurance company to overturn their denial and grant coverage on your behalf. An appeal generally consists of a formal letter, addressed to your insurance, explaining why a medication should be covered on your behalf and why your insurance’s initial denial should be overturned.
You have the right to appeal to your insurance’s coverage denial. Honest Care simplifies the appeals process by writing an appeal letter and supporting documents on your behalf making your best arguments for medication coverage, following your completion of our proprietary GLP-1 denial assessment.
If your insurance denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, you have the legal right to ask your insurance to reconsider the coverage denial by sending an ‘appeal’. Unfortunately coverage denials too often go unchallenged. A study from September 2023 found that 69% of people who were denied coverage by their insurance didn’t know they could appeal, and 85% of people never tried to appeal.
We believe it always makes sense to appeal. Here is why:
Appeals work: According to a study analyzing data from several U.S. states, patients who appealed directly to their insurance provider (an internal appeal) experienced a success rate between 39-59%.
Denials are often issued by mistake: A computer almost always makes the initial decision to deny medication coverage. This results in denials that don’t actually consider your personal health situation or denials made by mistake. In the case of Ozempic, Mounjaro, Wegovy and Zepbound, incorrectly entered information about your BMI, labs including A1c, your health conditions and diagnoses, your medication history and current medication use can all lead to an automatic denial. When you appeal, your information is reviewed by a real person.
Doctors review appeals, not computers: Having a doctor consider your unique circumstances makes submitting an appeal a powerful process for overturning denials getting covered.
You deserve the best care: You have the legal right to fight the treatment you need. As a part of the Affordable Care Act, all health insurance plans are required to allow their members to appeal their coverage decisions. This spans all insurance coverage - whether you are insured through your employer, purchased an insurance plan through your state marketplace, or are insured through a government program like Medicare or Medicaid.
We currently offer appeal services for Ozempic, Mounjaro, Wegovy and Zepbound. After purchasing Honest Care and completing your online denial assessment, you can expect to receive your appeal letter within 2 business days.
1. Online denial assessment: Complete the online assessment at your convenience that gather all the necessary appeal evidence for your insurance. The assessment reviews your medication history, including any GLP-1s, weight loss or diabetes medications you have taken, your health conditions and diagnoses, your past weight loss, diet and exercise attempts, and details on your insurance coverage and denial.
2. Case evaluation & appeal strategy: One of our dedicated appeal specialist will review your assessment and insurance denial and identify your best appeal arguments for coverage. This will include an evaluation of your medication history, medical diagnoses, weight loss attempts and clinical research studies that strength your appeal case.
3. Appeal letter & supporting documents: Your assigned appeal writer will compose a professional appeal letter addressing your denial reason and detailing your case for coverage. We’ll create a supporting evidence report that further justifies your appeal letter, to send your insurance along with your appeal.
4. Specialist Consultation & Support: After you receive and review your appeal letter & evidence, your dedicated appeal specialist will be available to answer your questions. They will be available to make updates to your appeal, if required. You will also have the option to schedule a phone or video call at a time of your convenience to you speak to your dedicated appeal specialist.
5. Send your appeal: You can submit your appeal yourself or have your doctor submit your appeal on your behalf. Most insurance companies accept appeals by mail or fax. Instructions on how to submitted appeal will be included within the written explanation on why you initially denied medication coverage, sent at the time at you were denied.
An insurance appeal is a formal request you make to your insurance company, asking them to reconsider a decision about your claim. This could be when they've denied your claim, not paid enough, or made a decision you disagree with. The appeal is your chance to argue your case, showing them why their decision should be different. It involves submitting a well-structured letter, along with any supporting evidence like medical records or repair estimates, to make your case stronger.
An insurance appeal letter is your way of asking the insurance company to reevaluate a decision, such as a denied claim. It's essentially your argument in writing, explaining why you believe their decision should be different. This is a common document patients can use to advocate for themselves with their insurance to cover their medical costs even prior to being denied for a treatment.
This letter will include your policy details, specific decision you disagree with, and provide solid reasons and evidence (like weight loss efforts, past and present medications, labs, receipts etc) for your appeal. The letter should be clear, concise, and respectful, ending with a specific request for what you want your insurance to do.
You can submit an appeal letter directly to your insurance or through your health care provider as part of your insurance appeal process.
Insurance supporting evidence is the documentation or information you provide to back up your claim or appeal with your insurance company. It's the proof that supports your case, like medical history, diet and exercise efforts, medication history, or relevant medical studies. This evidence is crucial because it shows the insurance company why they should approve your claim or reconsider a decision they've made.
We provide 3 types of supporting insurance evidence.
(1) Appeal Evidence - is the information you provide when you disagree with your insurer's decision about a claim or coverage. This could include detailed medical records, letters from your doctor explaining the necessity of a treatment, or information about how a treatment is standard for your condition. This evidence is crucial for challenging a denial or underpayment of a claim. Our role is to help you gather and present this evidence effectively, ensuring it clearly supports your need for the treatment or service claimed.
(2) Prior Authorization Evidence - is required when your health plan needs you to get approval before it covers certain medications or procedures. This evidence typically includes medical records, lab results, and a detailed rationale about why this specific medication or procedure is necessary for your condition. Our service involves assisting you in compiling comprehensive and relevant documentation to justify the medical necessity, aiming to secure approval from your insurance company for the required treatment.
(3) Step Therapy Exclusion Evidence - is used when you need to bypass the 'step therapy' protocol of your insurance plan. This protocol usually requires trying less expensive treatments before more costly ones are approved. Exclusion evidence might consist of medical records showing previous treatment attempts and failures, clinical data indicating why standard treatments are unsuitable or harmful for you, and detailed explanations about the necessity of the specific, often more expensive, treatment. We help you collect and organize this evidence to make a compelling case to your insurer that the standard step therapy process is not appropriate for your situation, thereby aiming for an exemption.
Working with your regular doctor can increase your chance of insurance coverage in several ways, including:
Yes - your Honest Care Report can be submitted to any doctor, including doctors working with online, telehealth-based GLP-1 clinics. Taking the Honest Care Assessment before engaging with a telehealth services presents several advantages, including helping you save money.
By using Honest Care before engaging with a telehealth company, you’ll find out how likely you are to get a GLP-1 prescription and will receive guidance on any recommended steps to take before your GLP-1 appointment. This can save you money by avoiding paying subscription fees until you’re fully prepared for your telehealth appointment.
There are nearly 10 GLP-1 medications available in the United States. Currently three of those medications, Zepbound®, Wegovy® and Saxenda®, are FDA-indicated for weight-loss assistance. The FDA indicates that people with a BMI ≥ 30 kg/m2 OR people with a BMI ≥ 27 kg/m2 who have been diagnosed with at least 1 weight-related condition are eligible for GLP-1s.
All other GLP-1 medications, including Ozempic® and Mounjaro®, are currently FDA-indicated for people diagnosed with Type 2 diabetes.
While FDA-guidelines are critical for understanding GLP-1 eligibility, there are a number of other factors to consider for determining GLP-1 eligibility.
Additional eligibility criteria that Honest Care takes into account include:
Prior Authorization (PA) is a process run by insurance plans to determine how necessary a medication is. Most insurance plans require Prior Authorization (PA) before approving coverage for GLP-1s.
After your GLP-1 prescription is written, your insurance plan will notify your doctor if a PA is required and ask your doctor for additional documentation on why your medication is necessary.
If a PA is required, your insurance plan will ask your doctor to submit detailed information on your diet and exercise history, your past weight loss attempts, weight loss medications you previously tried, and any unique challenges that you face that make a GLP-1 medically necessary.
The Honest Care Report includes evidence requested by most insurance plans and can be submitted to your insurance during the PA process. During your appointment, your doctor can attach your Honest Care Report to your health record so it is submitted as supporting evidence to your insurance if Prior Authorization is required.
