Wegovy Formulary Denials Explained

Key takeaways

  • If your request for Wegovy coverage was denied because the drug isn't listed on your plan's formulary, it means that your pharmacy benefit manager has chosen not to provide coverage for Wegovy.
  • Even if Wegovy isn't included in your formulary, you can still appeal the determination with a well-written appeal letter. Depending on your state of residence, your doctor can also submit a Formulary Exception Request on your behalf.
  • When preparing your appeal, it's crucial to gather all pertinent information concerning your weight, medical history, associated conditions, and previous attempts at lifestyle modifications.

Guide: Non-Formulary Denials for GLP-1s

  • What is a formulary?
  • “Not on Formulary” vs. Plan Exclusion
  • How to find out if coverage of Wegovy was denied for being non-formulary
  • Steps for writing an effective appeal

What is a formulary?

Your plan’s formulary is the list of medications they cover. It's created by your insurance provider's pharmacy benefit manager - or PBM - which is a third-party entity contracted to oversee medication coverage. Decisions about formulary inclusions are typically guided by a pharmacy and therapeutics (P&T) committee.

Insurance providers may opt to omit expensive medications from their formularies as a strategy to manage and reduce costs effectively. Because Wegovy (and most other GLP-1 medications) doesn’t currently have a generic alternative, most insurers will feature lower-cost alternatives such as Qsymia, phentermine, or Contrave on their formularies, sometimes as preferred step therapy options. For more information on step therapy, check out our blog article on Step Therapy Denials.

Common alternative medications to Wegovy may include:

Contrave
Orlistat (Xenical)
Phentermine (Adipex-P)
Plenity
Qsymia
Saxenda

“Not on Formulary” vs. “Plan Exclusion”

PBMs rely on guidance from a pharmacy and therapeutics committee to recommend which drugs should be included in their formularies and the order of their coverage. However, the final decision on included drugs rests with the PBM. If your Wegovy coverage request was denied because it's not on your plan’s formulary, this indicates the PBM has opted not to include Wegovy. You may seek to overturn this decision by having your provider submit a Formulary Exception Request or by submitting a well-crafted appeal.

On the other hand, a plan exclusion occurs when your employer specifically chooses not to cover Wegovy (or all weight loss medications) in your plan. Successfully appealing this type of exclusion can be challenging, as it hinges on the decisions made by your employer (and not your PBM) regarding plan coverage. For more information on exclusion denials, see our blog post on Weight Loss Plan Exclusion Denials, Explained.

How to find out if Wegovy coverage was denied for being non-formulary

To determine your denial reason, you’ll want to check your official denial letter, which your insurance provider will send to you by email or traditional mail. Here are a couple of examples you may see in a denial letter which indicates a medication is not on your formulary:

  • This request was denied because you did not meet the following requirements: The requested medication is not covered because it is not on the listing or formulary of approved drugs for your plan benefit. Please discuss alternative drug therapy with your doctor/plan.
  • Your request for coverage of Wegovy for weight loss has been determined as not medically necessary.  Per physician review, current plan approved criteria and current medical literature do not support the use of Wegovy over the available formulary alternatives.

If you don’t have your denial letter, you can try calling your insurance provider’s customer service line to ask for the denial reason. When you make the call, it’s a good idea to go ahead and ask about your appeal options and the appeal submission method required by your plan. Know that you have the legal right to appeal an insurance denial, and you can submit your appeal either on your own, or with the help of your provider.

Steps for writing an effective appeal

If your request for Wegovy medication coverage was denied, we strongly recommend filing an appeal. Honest Care takes the confusion out of the process with our free professionally written appeal letters. You’ll need to make a few minor edits to your letter to fully personalize it to your situation, but if you prefer, we can do all the editing for you with one of our full-service packages. Get started here.

Understanding Appeals

An appeal is a formal request to your health insurance provider to reassess an adverse determination for coverage of a medical therapy or service. Initial denial decisions for GLP-1 medications like Wegovy are typically automated. During the appeal process, a human reviewer evaluates your request and makes a decision. You can submit an appeal within six months of receiving your denial notice. When coverage is denied, insurers must provide an explanation for the denial and instructions on how to appeal, often through mail or fax. For general information on appeals, visit healthcare.gov.

Know Your Medical Background

If Wegovy isn't on your plan’s formulary, your pharmacy benefit manager likely has a tiered list of preferred drugs. To help your appeal, emphasize why these "preferred" alternatives are unsuitable for you.

  • Have you previously tried preferred medications? Document any trials of preferred medications, detailing dates, durations, effectiveness, weight changes, and side effects.
  • Are any of the preferred drugs contraindicated? Consider whether any medications pose physical or mental risks due to medical conditions, drug interactions, or side effects.
  • Are any of these medications ineffective? Insurance companies utilize cost-saving policies that often favor cheaper medication options, which may be less effective than GLP-1s like Wegovy. Include clinical research in your appeal demonstrating the superiority of Wegovy over required medications. For example, you might cite research studies showing that Orlistat or Phentermine is a less effective weight loss medication than Wegovy within your appeal.
  • Have you already seen success with Wegovy? A previous successful trial with Wegovy can potentially help sway your insurance provider to waive the formulary restriction and overturn your denial. If this is true for you, b‍‍e‍‍ ‍‍s‍‍u‍‍r‍‍e‍‍ ‍‍t‍‍o‍‍ ‍‍h‍‍i‍‍g‍‍h‍‍l‍‍i‍‍g‍‍h‍‍t‍‍ ‍‍t‍‍h‍‍e‍‍ ‍‍i‍‍m‍‍p‍‍o‍‍r‍‍t‍‍a‍‍n‍‍c‍‍e‍‍ ‍‍o‍‍f‍‍ ‍‍c‍‍o‍‍n‍‍t‍‍i‍‍n‍‍u‍‍e‍‍d‍‍ ‍‍t‍‍r‍‍e‍‍a‍‍t‍‍m‍‍e‍‍n‍‍t‍‍ ‍‍b‍‍y‍‍ ‍‍m‍‍e‍‍n‍‍t‍‍i‍‍o‍‍n‍‍i‍‍n‍‍g‍‍ ‍‍improvements in metrics like HbA1c, weight loss percentages, BMI reductions, and metabolic lab markers.
  • Highlight your previous efforts - When appealing a weight loss medication denial like Wegovy, insurers often value evidence of previous weight loss attempts through traditional methods.
    • Note any diets you’ve previously tried, such as Atkins or the Mediterranean Diet, and include receipts or check-in documentation from comprehensive programs like Weight Watchers or Noom.
    • Detail dates, duration, and effectiveness of any weight loss efforts, whether through nutritionists, gym memberships, personal trainers, or other means.

Emphasize expenses

Since formulary decisions prioritize cost, consider mentioning future expenses associated with untreated conditions like heart disease, stroke, Type 2 diabetes, and certain cancers. Addressing these potential costs can strengthen your case for coverage.

Submit your appeal

Review your denial letter to determine the submission method for your appeal. Some plans accept appeals by mail, while others allow electronic submission. Include your Member ID and claim number in the appeal header, as specified in your denial letter.

For more information on appeals for specific medications, check out our posts on appeals for Wegovy, Zepbound, Mounjaro, and Ozempic.

File your appeal

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Frequently asked questions

Why is 'Template' free?

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.

What is the Honest Care service guarantee?

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.

How does Honest Care help with insurance denials?

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.

Should I appeal if my insurance denied coverage?

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.

How does Honest Care’s paid appeal service work?

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.

What is an insurance appeal?

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.

What is an insurance appeal letter?

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.

What is supporting insurance evidence?

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.

How can working with a regular doctor increase your chance of insurance coverage compared to telehealth?

Working with your regular doctor can increase your chance of insurance coverage in several ways, including:

  • When your insurance plan is making a decision on whether to cover your GLP-1 prescription, they will want to review your medical history and recent labs results. Your doctor already has this information within your patient chart, and if you don’t have recent labs, your doctor can order new labs during your appointment. Most online, telehealth-based GLP-1 clinics do not have access to your full medical history in your patient chart, which limits their ability to achieve insurance approval.
  • In the event your insurance plan initially denies coverage for your GLP-1, this decision can be appealed by your doctor by writing a “Letter of Medical Necessity” and sending it your insurance company. Writing an effective letter requires a doctor to have a real relationship with their patient. Online, telehealth-based GLP-1 clinics find it challenging to write effective "Letters of Medical Necessity" given their lack of personal relationships with patients.
  • Insurance plans are increasingly flagging and scrutinizing GLP-1 prescriptions written by online, telehealth-based GLP-1 clinics. Working with a regular doctor can help avoid this additional scrutiny.

Can the Honest Care Report be shared with telehealth doctors?

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.

Who is eligible for GLP-1s?

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.

I already know I’m eligible for GLP-1s based on FDA-guidelines. How can Honest Care help me with eligibility?

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:

  • Weight-related conditions by importance in Prior Authorization (PA) - insurance plans often take certain conditions more seriously than others when determining GLP-1 eligibility.
  • Medication step therapy - many insurance plans only consider patients eligible for GLP-1 coverage only after trying lower-cost weight loss assistance medications first.
  • Ethnicity-based BMI guidelines for determining whether a patient is overweight by ethnicity.

What is Prior Authorization (PA)? Does Honest Care help with insurance?

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.