A formulary is a list of medications covered by your health plan, and is established by the pharmacy benefit manager (PBM) contracted by your insurance provider. PBMs are third-party entities tasked with managing medication coverage on behalf of insurers. The decisions regarding formulary inclusion are typically guided by a pharmacy and therapeutics (P&T) committee.
An insurance provider might opt to exclude expensive medications like Ozempic from its formulary as a cost-control measure. Given Ozempic lacks a generic alternative, insurers often feature lower-cost medications as alternatives on their formulary or prefer them for step therapy. For further insights into step therapy, refer to our blog post on Step Therapy Denials.
Common preferred alternatives to Ozempic on a formulary include:
• Metformin
• Rybelsus
• Victoza
• Byetta
• Trulicity
PBMs consult P&T committees for recommendations on drug inclusion and coverage order, but the final decision rests with the PBM itself. If your Ozempic coverage was denied because it isn't on your plan's formulary, it indicates the PBM's choice not to include it. You may challenge this decision by having your provider submit a Formulary Exception Request or by submitting a well-crafted appeal.
Because Ozempic is FDA approved for treating Type 2 diabetes, it is more likely to be categorized as non-formulary rather than completely excluded. A plan exclusion occurs when your employer deliberately opts not to include coverage for the medication or drug class in your plan, rather than your PBM. Winning an appeal of this nature, while not impossible, can be quite challenging due to the decision being tied to your employer's chosen plan. For more information on exclusion denials, see our blog post on Weight Loss Plan Exclusion Denials, Explained.
To identify the reason for your denial, start by reviewing your official denial letter, which your insurance company will send to you either by email or traditional mail. Here are examples of denial statements that might suggest your requested medication is not included in your insurance formulary:
If you cannot locate your denial letter (or have not received it yet), you can contact your insurance provider directly to ask why coverage was denied. While you're on the call, ask about the options available for appealing the decision and the preferred method for submitting an appeal according to your plan. Remember, you have the legal right to appeal an insurance denial and can choose to submit your appeal independently or with assistance from your healthcare provider.
If your request for medication coverage was denied for any reason, we encourage you to consider appealing. Honest Care offers free appeal letters, crafted by our team of experts, which require simple edits by you for full customization. If you’d prefer us to do all the legwork for you, we also have full-service packages available. Just take the assessment and wait for our team to write your letter. Get started here.
An appeal is a formal request submitted to your health insurance company asking them to review their decision to deny coverage for a medical therapy or service. Initially, denials for GLP-1 medications are often automated decisions made by computer systems. During the appeal process, your request is reviewed by a person who will assess your case and make a final decision. You typically have up to six months from the date of the denial notice to submit an appeal. When coverage is denied, your insurance company is obligated to provide an explanation detailing the reason for the denail as well as instructions on how and where to submit your appeal. Common methods for submitting an appeal include mailing a letter or sending it via fax. Visit healthcare.gov for general information on appeals.
If your request for Ozempic coverage was denied because it’s not on your plan’s formulary, it’s likely your PBM has a list of medications your insurance provider prefers to cover over Ozempic - these preferred drugs will be organized in a tiered system. When appealing your denial, you’ll want to make a case for yourself on why these “preferred” medications will not work for you.
Make sure to document any steps you've taken toward better health, particularly focusing on improvements in your HbA1c levels. This includes detailing specific diets or programs you've followed. If you've participated in a paid health management program or consulted with a nutritionist, consider including receipts with your appeal. Since Ozempic is meant to complement a healthy lifestyle including diet and exercise, mention any memberships to gyms or participation in exercise programs.
Since formulary decisions are based on medication cost, it can be helpful to highlight potential future expenses if your condition remains untreated. Treating conditions linked to diabetes, such as heart disease, stroke, and Metabolic Syndrome, can significantly outweigh the costs associated with covering your requested medication now.
Review your denial letter (or contact your insurance provider) to determine the preferred method for submitting your appeal. Some plans require appeals via traditional mail, while others accept electronic submissions. Your denial letter will specify where to send your appeal. Ensure your appeal includes your Member ID and claim number in the header.
For more information on appeals for specific medications, check out our posts on appeals for Wegovy, Zepbound, Mounjaro, and Ozempic.
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.
