[Updated: June 20, 2024] Have you recently been denied insurance coverage for Zepbound? In this article, we’ll explain how to overturn the denial by submitting a Zepbound appeal.
If you're reading this article, chances are you have been denied coverage for Zepbound or anticipate you might be denied if you try. You might have heard of the ‘appeals’ process and are wondering if it makes sense for you to appeal, and if so, how to appeal.
Let’s start with the basics - what is insurance appeal? An appeal is a formal request to your health insurance company to reevaluate its decision to deny coverage for a medical therapy or service. You have the right to initiate an appeal within six months of the denial notice. In this process, the insurance company is obligated to both clarify the reasons for denying your claim and guide you on how to contest, or appeal, their decision. Visit healthcare.gov for general information on appeals.
Honest Care has you covered with our step-by-step guide for Zepbound appeals. Feel free to skip the sections of this guide that are most relevant to you.
Need Help Appealing? Explore Honest Care's GLP-1 appeal service.
Key Takeaway: You have the legal right to fight for the treatment you deserve, and appeals often succeed. If starting or continuing treatment on Zepbound is important to you, then appealing is worth the effort.
Before digging into the details of how to appeal, you might be asking whether it makes sense to appeal based on your unique circumstances.
In short, it’s almost always worth appealing. Here is why:
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%.
A computer almost always makes the initial decision to deny Zepbound coverage. This results in denials that don’t actually consider your personal health situation or denials made by mistake. In the case of Zepbound, incorrectly entered information about your BMI, your health conditions, 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.
Having a doctor consider your unique circumstances makes submitting an appeal a powerful process for getting Zepbound covered.
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.
Key Takeaway: Identifying the specific cause of denial will help you form an effective appeal strategy. Need help navigating your insurance denial? Try Honest Care's appeal services.
To effectively appeal for Zepbound coverage, it is critical to understand why you were denied to begin with. Your insurance is obligated to provide you a written explanation on why you were denied, which is often referred to as the “Explanation of Benefits”.
Some common reasons for denial are:
This means that Zepbound 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 Zepbound, such as Saxenda. If Zepbound is not on your plan’s medication list, you will specifically ask for a “formulary exception” within your appeal.
If your insurance thinks you don’t meet the medical requirements for Zepbound, 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 Zepbound necessary within your appeal.
Many insurance plan’s ask that patients try alternative weight loss treatments before Zepbound, such as Contrave, Phentermine, Orlistat, Qsymia or sometimes Wegovy. 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 Zepbound 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 1lb per week). Be sure you’re aware of the requirements of your plan so you can directly address them.
There is a chance that Zepbound 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 Zepbound now will save your insurance plan later. Read our guide on Weight Loss Plan Exclusion Denials.
Key Takeaway: Including supporting evidence helps justify your request for coverage summarized in your appeal. Need help? Honest Care can help you gather your Zepbound supporting evidence.
Be sure to compile as much evidence as you can regarding obesity, cardiovascular and diabetes-related conditions you may have (such as prediabetes, cardiovascular disease, hypertension, or metabolic syndrome). Recent labwork such as your HbA1c level and metabolic panels can be helpful. If you’ve already been on treatment with Zepbound or tirzepatide, be sure to highlight any positive changes you’ve seen in your labs if you have that information available. Include any weight loss information as a secondary positive to your labs.
If you DO have Type 2 diabetes but you didn’t provide enough information in the original coverage request, you should include as much information you can provide surrounding your diagnosis. This can include the year you were diagnosed, your most recent A1c level, and (if you’ve already been on treatment with Zepbound) any positive effects you’ve seen in your labs and blood sugar management.
If your plan has requirements surrounding step therapy and/or preferred treatments, be sure to put together a list of any medications you’ve previously tried for your diagnosis. For Zepbound, some common preferred meds are phentermine, Qsymia, Orlistat, and Saxenda. Be sure to check your plan’s formulary for their list of preferred medications. Compile the dates and durations you took each medication, the effectiveness of the medication, and any side effects you experienced. If you haven’t tried any step therapy medications, put together a plan with your doctor to discuss why these medications are not appropriate for you in your appeal. Read our guide on Step Therapy Denials.
If your denial was because of failure to demonstrate lifestyle modification, your best bet here is going to be to gather as much information as you can regarding your current and past lifestyle modification attempts with diet and exercise. 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 have duration requirements for participation, usually 3-6 months.
Along with the above, you should also address continuation of therapy if you’ve already been on treatment with Zepbound or Tirzepatide. GLP-1 medications are meant to be taken consistently, usually with regular titrations (or moving up in dosage), so it’s always a good idea to list this in an appeal letter if possible. Be sure to include the year you began and how long you took the medication, your starting and ending (or current) weights, and other clinical data such as positive effects on your A1c, metabolic labs, or comorbidity markers.
Key Takeaway: An effective appeal letter addresses your reason for Zepbound denial and summarizes your health history, past medications you have tried, and your weight loss attempts through diet and exercise. Need help? Honest Care can write your appeal letter.
Because each person has unique circumstances, there isn’t an exact science to writing an effective Zepbound appeal letter. That said, there are best practices or “ingredients” to consider to write an effective letter. Here is what we recommend:
First things first - make sure your letter is destined for the right place! The heading of your letter should include the name and address of your insurance’s appeals department. This information can be found on your denial letter. You should also include the case number from your determination letter, as well as your Member ID.
At the start of your letter, be clear that you are requesting coverage for Zepbound and summarize your insurance’s reason for denying coverage.
Zepbound is approved by the FDA for the Any aspect of your medical history that makes it obvious that is the right treatment for you should be included. Include your BMI and any weight-related conditions you have been diagnosed with (e.g. Prediabetes, Hypertension, High Cholesterol, Metabolic Syndrome).
You may have tried medications before Zepbound, organized weight loss programs, bariatric surgery, etc. Summarize these attempts and why those attempts demonstrate that Zepbound coverage is critical for you.
Gather articles from peer-reviewed clinical journals that validate the efficacy and necessity of Zepbound. Utilize resources like PubMed.gov or Google Scholar for your research.
Not all circumstances are properly captured within medical records or clinical data. Within your appeal letter, take the opportunity to explain your unique circumstances. These can help make a compelling argument within your appeal about why Zepbound should be covered.
Your insurance will specify the exact details on how to submit your appeal. Below are a few important questions to answer before you submit your appeal:
Know who you’re submitting to and include that information in the header or cover sheet. Are you submitting to your insurance provider, or to your pharmacy benefits provider? Is there a specific department listed on your denial letter? Be sure to include all pertinent information on your envelope, in your email subject, or on your fax cover letter - depending on how you’re submitting.This is frequently found on your Explanation of Benefits that is sent upon denial. You can also call your insurance to ask for this information.
If you’re submitting your appeal yourself rather than having your doctor submit for you, be sure to thoroughly read your denial letter and any accompanying documentation to determine HOW your letter needs to be sent. Some insurance providers allow electronic submission, while others prefer fax or submission over the phone. Still others will require you to submit your letter by mail. Make sure you double check addresses and phone numbers to make sure your letter gets into the right hands.
If your appeal will be submitted by your doctor, it can be helpful to go over your letter and accompanying evidence with your provider to make sure all information is cohesive. Oftentimes your doctor will have their own page of information they’ll submit with your letter, and it’s important to be sure all information aligns.
Insurance companies usually quote a timeframe between 30 and 60 days to process an appeal determination. Keep notes of when you submitted your appeal so you can call your insurance to check in if you haven’t received a determination within their listed timeframe.
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.
