[Updated May 21, 2024] Before approving coverage for Ozempic, Mounjaro, Wegovy or Zepbound, your insurance may have a policy that you try cheaper, "preferred" medications first ("Step Therapy"). Those working outside of insurance often to refer to the requirement as “Fail First”.
Step Therapy is often required because it an effective way for your insurance company to control and low its costs. When you are prescribed a GLP-1 like Zepbound or Mounjaro, your insurance may ask you try a cheaper alternative medication first. Only after you demonstrate that the drug failed to be effective will your insurance cover your originally prescribed GLP-1 on your behalf.
If your insurance denied coverage for your GLP-1 prescription based on a request for step therapy, you have the legal right to ask your insurance to reconsider the coverage denial by sending an ‘appeal’. It almost always makes sense to appeal, but many people don’t. 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.
Honest Care has you covered with our guide to Step Therapy Denials and Appeals for Ozempic, Mounjaro, Wegovy and Zepbound. Feel free to skip the sections of this guide that are most relevant to you.
Need Help Appealing a Step Therapy Denial? Explore Honest Care's GLP-1 appeal service.
Let's say you have been prescribed Zepbound (tirzepatide) and denied coverage for Zepbound by your insurance with a denial reason of failure to meeting step therapy requirements and a request for you to try alternative medications first. This means that instead of (or in addition to) Zepbound, your insurance provider has listed generic and/or "preferred" weight-loss medications on your plan's formulary (list of covered medications) that they request you try first. Your denial letter may include an explanation similar to the below:
Step Therapy Denial Letter Example
Your plan only covers this drug when you meet one of these options: A) You have tried other drugs your plan covers (preferred drugs), and they did not work well for you, or B) Your doctor gives us a medical reason you cannot take those other drugs. For your plan, you may need to try up to three preferred drugs. We have denied your request because you do not meet any of these conditions. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. The preferred drugs for your plan are: orlistat, QSYMIA, SAXENDA, WEGOVY (Requirement: 3 in a class with 3 or more alternatives, 2 in a class with 2 alternatives, or 1 in a class with only 1 alternative). Your doctor may need to get approval from your plan for preferred drugs. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for your review.
Let's break down how the medications mentioned in the above denial example fall into "steps" or "tiers" on common, 3-tier formulary plan. Some plans include 4 or 5-tier formulary plans that may slightly differ from the below.
If you have been denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, it may be because you did not meet the ‘step therapy’ requirements outlined by your insurance plan. The easiest way to understand if this is why you were denied is to review the coverage denial letter sent by your insurance, often referred to as an “Explanation of Benefits”. Read the section "What is an example of Step Therapy denial?" above for more details.
Key Takeaway: Step therapy denials can be overturned with an effective appeal strategy. Need help navigating step therapy denial? Try Honest Care's appeal services.
Even if you have not tried the step therapy medications required by your insurance, coverage denials can still be overturned through an effective appeal. Exceptions to step therapy requirements can be made based on several conditions which can be detailed in your appeal, including:
Each insurance provider establishes their own step therapy requirements, including which medications are included within each step therapy "tier" on their formulary. Below we've listed the most common medications mentioned by insurance
Key Takeaway: Depending on which state you live in, your doctor may be able to file a request for a step therapy exception with your insurance. While you can submit appeals on your own or through your doctor, only your doctor can file a step therapy exception for on your behalf.
Certain US states have put in place protections to help patients bypass step therapy requirements by filing for a “Step Therapy Exception.” Step Therapy Exception Requests must be filed by your doctor.
Step Therapy Exception rules vary not only by state, but also type of insurance. In most cases, state laws apply to anyone covered by a commercial insurance plan, including employer-sponsored plans, individuals plans through insurance exchange (Affordable Care Act), and fully-insured employer plans. Certain state Medicaid programs also have adopted step therapy protections.
Here is a list of states where some level of step therapy protections in place as of 2023, and a link to the state's step therapy exception request form if available. This list is not exhaustive, so please talk to your doctor for more information.
Arizona (exclusion form)
Arkansas (exclusion form)
California (exclusion form)
Connecticut (exclusion form)
Delaware (exclusion form)
Florida (exclusion form)
Georgia (exclusion form)
Illinois (exclusion form)
Indiana (exclusion form)
Iowa (exclusion form)
Kansas
Kentucky (exclusion form)
Louisiana (exclusion form)
Maine (exclusion form)
Maryland (exclusion form)
Massachusetts
Minnesota (exclusion form)
Mississippi (exclusion form)
Missouri (exclusion form)
Nebraska (exclusion form)
Nevada
New Mexico (exclusion form)
New York (exclusion form)
North Carolina (exclusion form)
Ohio (exclusion form)
Oklahoma (exclusion form)
Oregon (exclusion form)
Pennsylvania
South Dakota (exclusion form)
Tennessee
Texas (exclusion form)
Washington (exclusion form)
West Virginia (exclusion form)
Wisconsin (exclusion form)
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.
