What to do if your insurance won't cover GLP-1s

Key takeaways

• If your insurance denies coverage for glucagon-like peptide-1 receptor agonists (GLP-1s), you can file an appeal within 6 months. Around 44% of insurance denials are successfully appealed.
• Common reasons for denial include not meeting criteria like body mass index (BMI) requirements, lacking prior authorization, or not completing step therapy with lower cost treatments first.
• If your appeal is denied, savings options include manufacturer programs, prescription discount cards, self-pay options, and exploring alternative medications covered by your insurance formulary.

Overview

Glucagon-like peptide-1 receptor agonists (GLP-1s) like Ozempic and Wegovy are increasing in popularity. But these drugs are still fairly new, and they’re often associated with high costs.

Insurance coverage for GLP-1s is increasing, but it’s still common for insurance plans to reject GLP-1 coverage. You might need to meet certain requirements before your coverage will be approved. Let’s take a look at how to navigate insurance denials, file appeals, and save on your GLP-1 costs.

Learn more about how much GLP-1s cost.

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File an appeal

 If your insurance has rejected coverage, you can appeal the decision. This will make your insurer take another look at your circumstances. Most initial denials are automated, and according to data from 2023, around 44% of insurance denials are successfully appealed.

You must submit an appeal within 6 months. Here’s a step-by-step guide for how to appeal a denial:

Step 1: Understand why you were denied

If your coverage is denied, your insurer should let you know why. This should help you gather the evidence you need to prove why the medication should be covered.

For example, if your insurer thinks you don’t meet the criteria, you can gather documents showing that you do.

Step 2: Write your appeal letter

Every appeal letter will look different. But here are some tips you can follow for writing the letter:

• Make sure you have the correct policy number and appeal department.
• Include the reason for the denial and your request.
• Detail your health history, including previous treatments that you’ve tried.
• Explain why the GLP-1 is the most effective treatment for you.
• Mention the risks associated with stopping treatment.

Your doctor can help you with this process.

Medical perspective

How long will it take to hear back from an insurance appeal?

“Most insurance appeals can range anywhere from a few weeks to months. This depends on how urgent the case is and whether all the needed documents have been provided. If additional information or clarification are needed, this can cause the decision to take longer.”

— Alex Nguyen, PharmD, RPh, CPh

Note: Quotes represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.

Look into savings options

If your appeal has been denied, there are many other ways to save on the costs of GLP-1s:

• Manufacturer savings programs: Many GLP-1 manufacturers have savings programs that can be used alongside insurance to reduce the cost of your copay, but they can also help you save on the list price even if your insurance won’t cover the drug.
• Self-pay options: Some manufacturers offer fixed, reduced pricing for patients paying entirely out of pocket. These often offer other benefits like home delivery.
• Prescription discount cards and coupons: Some third-party companies, including Optum Perks, offer a free or low cost discount card that can help you save on many medications, including GLP-1s.
• Government programs: TrumpRx is a platform that allows people to find and access discounted drug prices for some prescription drugs, including GLP-1s. Medicare is also expanding coverage for GLP-1s for obesity.

Look into alternative medications

Another option is to look into alternative medications that are covered by your insurance. For diabetes, these might include metformin (Riomet) or insulin. For obesity, there are options like naltrexone-bupropion (Contrave) and phentermine-topiramate (Qsymia).

You can check your insurance formulary, also known as a drug list, to see what is more likely to be covered. And, if these options ultimately don’t work for you, they can count as proof that a GLP-1 should be covered in the future.

A note on compounded GLP-1s

Some pharmacies offer compounded GLP-1s, which are custom-mixed versions of the drug that tend to be cheaper than branded versions.

It’s important to note that these are not approved by the Food and Drug Administration (FDA), which means that the FDA has not verified the safety, effectiveness, or quality of the compounded drugs before they’re sold.

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Why might insurance reject GLP-1s?

There is a lot of variation among employer-sponsored and private insurance plans as to whether GLP-1s are covered. Here are some common reasons for denials from insurance companies:

You don’t meet the criteria

Many insurers require a treatment to be medically necessary before they’ll agree to cover it. This usually means they’ll only prescribe a GLP-1 if it’s being used for an approved purpose. Ozempic, for example, is approved for blood sugar management, whereas Wegovy is specifically approved for weight management.

You might need to meet specific criteria, such as a specific body mass index (BMI) or blood sugar levels, for your insurer to agree to cover the drug.

You haven’t tried step therapy

Step therapy is where you must show that you have tried other, lower-cost treatments that haven’t worked before insurance will cover GLP-1s. You may need to provide proof that you have tried, for example, a reduced-calorie diet and exercise, or you’ve tried managing blood sugar with cheaper, generic medications.

You don’t have prior authorization

Prior authorization (PA) is when your insurance provider requires a doctor to prove that a treatment is medically necessary before agreeing to cover the cost. If a drug requires prior authorization and you receive it without the insurer’s approval, your health plan may not cover your treatment, leaving you responsible for the full cost.

If a GLP-1 for weight management requires PA, insurers may ask the prescribing doctor to show:

• proof that you meet certain health criteria
• that you have tried step therapy
• that you’re enrolled in a supervised weight-management program or digital health app to track progress
• proof that you have engaged in lifestyle changes, like a reduced-calorie diet

The doctor will handle this process, and you won’t need to do much yourself.

Online care for GLP-1s

If a doctor has prescribed a GLP-1, it’s important to take the medication as directed for as long as your doctor recommends. However, some people might face barriers to accessing GLP-1s, including high costs and access to healthcare appointments.

With Optum Perks Online Care, you can request a new weight loss prescription, get a refill, or get help with an existing prescription. There’s no monthly membership needed — all you’ll pay is $29 for the appointment plus the cost of the medication.

With this service, you can submit an online form answering a few questions about your condition, and a licensed healthcare professional will respond soon after, without the need to make an in-person appointment.

Next steps

If your insurance has refused coverage for a GLP-1, it isn’t the end of the road. You can:

• submit an appeal
• look into savings to pay for the medications yourself
• try alternatives first

Always speak with your doctor about your options. They can help you write an appeal, find savings, or decide on alternatives.

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