GLP-1 Insurance Coverage
Getting Your Medication Approved & Covered
Navigate the insurance maze for Ozempic, Wegovy, Mounjaro, and Zepbound. Prior authorization tips and appeal strategies.
Coverage by Plan Type
Getting Prior Authorization Approved
Document Everything
Your doctor should include: diagnosis codes (E11.9 for T2D, E66.9 for obesity), BMI history, failed diet attempts, comorbidities.
Include Lab Values
A1C levels, fasting glucose, lipid panels, and liver function tests strengthen the case for medical necessity.
Be Persistent
Prior auths are often initially denied. The first denial is not the final answer—always appeal.
Call the Insurance
Have your doctor's office call the insurance company directly. Often faster than faxing forms.
How to Appeal a Denial
- 1. Get the denial in writing: Request the specific reason code and criteria they used to deny.
- 2. Review your plan's criteria: Often the denial is due to missing documentation, not ineligibility.
- 3. Have your doctor write a letter: A letter of medical necessity explaining why this specific medication is needed.
- 4. Include peer-reviewed studies: Attach clinical trial data showing efficacy for your condition.
- 5. Request a peer-to-peer review: Your doctor can speak directly to the insurance's medical director.
- 6. File an external appeal: If internal appeals fail, you can request an independent review.
The Diabetes vs Weight Loss Distinction
Important: Insurance coverage differs dramatically based on indication:
- • Ozempic is FDA-approved for Type 2 diabetes only. Better insurance coverage.
- • Wegovy is FDA-approved for weight management. Often excluded from coverage.
- • Mounjaro is approved for T2D. Zepbound (same drug) is approved for weight loss.
If you have T2D, Ozempic or Mounjaro will be easier to get covered. If you only want weight loss, expect more hurdles.
FAQ
Why won't my insurance cover Wegovy?
Many plans specifically exclude "weight loss drugs" from coverage. This is a policy decision, not a medical one. Some employers are adding coverage due to demand.
Can I use Ozempic for weight loss even though I'm not diabetic?
Doctors can prescribe "off-label," but insurance may not cover it. You'd likely pay cash price. Wegovy is the on-label option for non-diabetic weight loss.
What's step therapy?
Some plans require you to try cheaper medications first (like metformin) before approving GLP-1s. Your doctor can sometimes get an exception if these aren't appropriate for you.
Track Your GLP-1 Journey
Once approved, use Shotlee to track your injections, side effects, and weight loss progress.
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