[Updated May 23, 2024] Has your insurance denied you for GLP-1 weight loss medications like Wegovy and Zepbound? There are many reasons why you could be denied. In this article we'll explore "plan exclusions", what are they and how best to navigate them.
It’s estimated that currently only about 25% of employers include coverage for Zepbound, Wegovy and other weight loss medications in their offered insurance plans. If you’ve been denied coverage for Zepbound or Wegovy, it’s possible that your denial due is due a weight loss plan exclusion.
Due to the increasing need for GLP-1 medications such as Wegovy, Ozempic, Mounjaro and Zepbound, a reported 43% of employers plan to offer coverage in the near future. While we’re hopeful that many more employers will jump onboard, in the meantime, Honest Care has you covered with our guide to Weight Loss Plan Exclusion Denials for GLP-1s.
If your insurance plan excludes weight loss medications, this means that your employer has selected an insurance plan that will not offer coverage for any medication used for weight management. This means that Zepbound, Wegovy will not be listed on your plan’s drug formulary, and alternative weight loss medications such as Contrave and Qsymia will also be excluded. In this case, a prior authorization or other request for coverage will usually receive a denial.
If you were denied coverage for a GLP-1 or other weight loss medication, there are multiple reasons your insurance provider could have denied coverage, with a plan exclusion being one of them. To find out the reason for the coverage denial, consider the following steps:
Your insurance plan is required to send you an explanation of why they denied coverage, either by traditional mail or email. This is often referred to as an “Explanation of Benefits.” If you have been denied coverage due to a weight loss plan exclusion, this should be stated in the letter. Your denial letter may exclude language similar to the below:
Weight Loss Plan Exclusion, Example Denial Letter
Example #1
"We denied this request based on general exclusion section of formulary. Zepbound is classified as a weight loss medication. Your plan does not cover weight loss medications under your pharmacy benefit. We make PA decisions based on the information given to us by your healthcare practitioner at the time services are provided. We also base decisions on your benefit, as outlined in your plan description."
Example #2
"We denied your request because your plan only covers this type of drug for certain use (treatment of obesity). We do not see that this applies to you. We based this decision on your Pharmacy Health Plan Benefits under the section titled ""Weight Loss Drugs"" under What Is Not Covered in your benefit plan. Weight Loss Medications are an exclusion under your plan benefits and are not covered."
One common cause of confusion is understanding the difference between an insurance denial due to a weight loss medication not being on formulary, versus a denial due to a weight loss plan exclusion. If you have been denied coverage for Wegovy or Zepbound due the medication not being on formulary, this does necessarily mean your plan includes a total weight loss exclusion, but could mean that just Wegovy or Zepbound is specifically not covered. Below is a denial letter language for Zepbound not being on formulary, rather than due to a weight loss plan exclusion.
Not on Formulary, Example Denial Letter
"Unfortunately, we must deny coverage for Zepbound. Why was my request denied? This request was denied because you did not meet the following requirements: The requested medication and/or diagnosis are not a covered benefit and are excluded from coverage in accordance with the terms and conditions of your plan benefit. Therefore, this request has been administratively denied."
Prior authorizations and other coverage requests are submitted by your healthcare provider (whether you see an in-person practitioner or are utilizing a telehealth program). Oftentimes, your provider will receive the determination before you do, especially if the request was submitted electronically. They’ll also receive a copy of the denial letter with the reason for the denial.
You may encounter long wait times or multiple transfers, but you can also call your insurance directly to inquire about the status of your coverage request. Most insurance providers utilize a PBM - or pharmacy benefit manager - which is a third party that manages your prescription drug benefits. CVS Caremark, Optum Rx, and Express Scripts are the three largest PBMs, and your plan likely uses one of these most common options. If you know your plan’s PBM, it may be more beneficial to contact them directly.
Key Takeaway
If you’d like help with your appeal letter, consider letting our dedicated team assist. Take Honest Care’s free assessment.
If you’ve received a denial for coverage of any medication (not just weight loss drugs), you have the legal right to appeal this decision to your insurance (and we believe you should!). While appeals for weight loss plan exclusions are difficult to win, there are cases of successful appeals (an example for reference) and there is no penalty for attempting to appeal. For more information regarding appeals, please see our respective posts on Wegovy, Ozempic, Mounjaro, and Zepbound appeals.
Wegovy and Zepbound are currently FDA approved for the treatment of obesity, while Ozempic and Mounjaro are labeled for use in Type 2 diabetics. However, GLP-1 medications are showing promise in studies for the treatment and prevention of other conditions. For example, Wegovy has been clinically linked to a 20% lower risk of major cardiovascular events (such as heart attack and stroke), and Mounjaro and Zepbound have show promise for reduced risk of Metabolic Syndrome and Cardiovascular Disease. If you’ve been diagnosed with any weight related health conditions, consider discussing off-label use of a GLP-1 with your provider.
Your employer ultimately determines the insurance plans they offer their employees. If your insurance plan contains a weight loss plan exclusion, something you can do right now is contact your employer’s HR department and ask them to reconsider the plans they offer their employees in the next enrollment period.
While you’re going head-to-head with your insurance company, consider doing the same with your employer and request that they choose a health plan which includes coverage of weight loss medication for the next enrollment period. To make it easy, we’ve done the legwork and drafted a comprehensive sample letter that you can download and submit to your employer’s HR department. Be sure to include your name at the bottom of the letter.
The more people you can get in on the action, the better. And we’ve got you covered here, too. If you feel comfortable reaching out, you can send this PDF to any coworkers you feel may want to help advocate for coverage of weight loss medications on your company’s health plan. Be sure to send the employer letter to them as well. And you don’t have to stop with your coworkers. If you have friends or relatives who are also dealing with a weight loss plan exclusion on their employer funded insurance plan, consider sharing this information with them. As more employers feel the pressure to include weight management coverage on their plan’s formularies, insurance providers will begin to get the message as well.
To Whom it May Concern,
I’m writing regarding an issue I’ve recently experienced with my medical insurance coverage. After speaking with my doctor and insurance provider about GLP-1 medications for the treatment of obesity, I was frustrated to learn that weight loss medications are an employer exclusion under my plan. I am formally requesting that you reconsider this plan exclusion and allow for the coverage of weight loss medications, specifically GLP-1 agonists.
According to data from the CDC, obesity is a condition that affects more than 40% of Americans. Recent studies have shown that GLP-1 medications are far more effective in helping individuals treat obesity compared to diet and exercise alone.For example, the STEP 1 study proved that participants receiving weekly doses of 0.4 mg semaglutide, in conjunction with diet and exercise, experienced far superior weight reductions (between 14.9% and 16.9%) compared to the average 2.4% seen by those in the placebo group.
The CDC also underscores the fact that obesity related conditions - including heart disease, stroke, Type 2 diabetes, and some cancers - are among the leading causes of premature and preventable deaths. However, multiple studies show that GLP-1 medications can have a positive effect on these conditions along side eight loss. Regarding semaglutide, a large study involving 17,604 individuals showed a significant reduction in primary cardiovascular events at a 6.5%incidence rate compared to 8% in the control group over the course of three years. Regarding heart disease and tirzepatide, the SURMOUNT-1 phase III clinical trial showed a notable reduction in cardio-metabolic risk variables in individuals who took tirzepatide over the course of 72 weeks (-23.5%) compared to those in the placebo group (-16.4%).
Obesity affects a large portion of the population, and effective treatment options can be impossible to obtain without insurance coverage due to high out-of-pocket costs. The exclusion of these medications from a medical insurance formulary denies treatment to those who need it. The estimated cost of treatment for obesity-related conditions that are likely to develop or worsen due to untreated obesity can far exceed the cost of covering obesity treatment itself. With all of these factors in mind, I ask you to please offer coverage of weight loss medications on our insurance formulary for the next enrollment period.
Best regards,
[Name]
[Contact number]
Friends and coworkers,
It has recently come to my attention that our current medical insurance plan excludes the coverage of medications intended for weight loss. It’s estimated that around 40% of Americans are affected by obesity, and obesity-related health conditions are among the leading causes of preventable deaths in the nation.
With this in mind, I ask you to please join me in requesting coverage of these life saving medications on our formulary during our next open enrollment period. To make it easy, I’m including a letter of this request. All you need to do is copy and paste the sample letter below into an email to HR, being sure to include your name at the end.
I hope you’ll join me in advocating for so many individuals who need access to these medications.
All the best,
[Your name]
-- SAMPLE LETTER BELOW --
To Whom it May Concern,
I’m writing regarding an issue I’ve recently experienced with my medical insurance coverage. After speaking with my doctor and insurance provider about GLP-1 medications for the treatment of obesity, I was frustrated to learn that weight loss medications are an employer exclusion under my plan. I am formally requesting that you reconsider this plan exclusion and allow for the coverage of weight loss medications, specifically GLP-1 agonists.
According to data from the CDC, obesity is a condition that affects more than 40% of Americans. Recent studies have shown that GLP-1 medications are far more effective in helping individuals treat obesity compared to diet and exercise alone.For example, the STEP 1 study proved that participants receiving weekly doses of 0.4 mg semaglutide, in conjunction with diet and exercise, experienced far superior weight reductions (between 14.9% and 16.9%) compared to the average 2.4% seen by those in the placebo group.
The CDC also underscores the fact that obesity related conditions - including heart disease, stroke, Type 2 diabetes, and some cancers - are among the leading causes of premature and preventable deaths. However, multiple studies show that GLP-1 medications can have a positive effect on these conditions along side eight loss. Regarding semaglutide, a large study involving 17,604 individuals showed a significant reduction in primary cardiovascular events at a 6.5%incidence rate compared to 8% in the control group over the course of three years. Regarding heart disease and tirzepatide, the SURMOUNT-1 phase III clinical trial showed a notable reduction in cardio-metabolic risk variables in individuals who took tirzepatide over the course of 72 weeks (-23.5%) compared to those in the placebo group (-16.4%).
Obesity affects a large portion of the population, and effective treatment options can be impossible to obtain without insurance coverage due to high out-of-pocket costs. The exclusion of these medications from a medical insurance formulary denies treatment to those who need it. The estimated cost of treatment for obesity-related conditions that are likely to develop or worsen due to untreated obesity can far exceed the cost of covering obesity treatment itself. With all of these factors in mind, I ask you to please offer coverage of weight loss medications on our insurance formulary for the next enrollment period.
Best regards,
[Name]
[Contact number]
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.
