Winning the Insurance Battle: GLP-1 Prior Authorization and Appeals

Getting insurance to cover GLP-1 medications can feel like a full-time job. Prior authorizations, step therapy requirements, denials, appeals—the process is frustrating by design. But it's winnable. With the right approach, many patients who are initially denied eventually get coverage.

This guide walks through the process: what insurers require, how to meet those requirements, and what to do when they say no.

The Coverage Landscape

Insurance coverage for GLP-1 weight loss medications varies dramatically:

• Medicare: Generally does NOT cover weight loss medications (though covers for diabetes)
• Medicaid: Varies by state; some cover, many don't
• Employer plans: Highly variable; trend toward coverage is increasing
• ACA marketplace: Often excludes weight loss drugs unless state mandates coverage

The first step: check whether your plan covers GLP-1 medications at all. Call your insurance or check your formulary. If weight loss drugs are explicitly excluded, prior authorization won't help—you'll need alternative strategies.

Standard Prior Authorization Requirements

For plans that do cover GLP-1 medications, prior authorization typically requires:

Medical Criteria

• BMI ≥30 (obesity), OR
• BMI ≥27 with at least one weight-related comorbidity (diabetes, hypertension, sleep apnea, etc.)
• Documentation of weight-related condition(s)

Prior Attempts

• 3-6 months of documented supervised weight loss attempt
• May require specific program (dietitian, physician-supervised)
• Documentation of calories, exercise, weight tracking

Step Therapy

Some insurers require trying (and failing) cheaper medications first:

• Phentermine
• Topiramate
• Naltrexone-bupropion (Contrave)
• Orlistat (Alli/Xenical)

Provider Requirements

• Prescription from specific provider types (sometimes excludes telehealth)
• May require endocrinologist, bariatric specialist, or specific certification

Preparing a Strong Prior Authorization

When You're Denied: The Appeal Process

Initial denial isn't the end. The data on appeals is encouraging:

The most important statistic: 85% of denied patients never appeal. Insurers count on this. Simply filing an appeal puts you ahead of most people.

Internal Appeal

• Usually must file within 30-180 days of denial
• Include additional documentation addressing specific denial reasons
• Request peer-to-peer review (your doctor speaks directly with insurer's medical director)
• Cite clinical guidelines and evidence

External Appeal

If internal appeal fails, you have the right to external review by an independent third party. This is often more favorable than internal review.

The Diabetes Route

A commonly used strategy: if you have type 2 diabetes or prediabetes, GLP-1 medications may be covered for diabetes even when excluded for weight loss.

• Ozempic (semaglutide 1mg) is a diabetes drug
• Mounjaro (tirzepatide) is approved for diabetes
• Coverage is often better with diabetes diagnosis

If you have prediabetes (A1C 5.7-6.4%), some providers will prescribe Ozempic or Mounjaro for diabetes prevention, potentially with better coverage than weight loss indications.

Manufacturer Programs

Both Novo Nordisk and Eli Lilly offer programs that can dramatically reduce costs:

Novo Nordisk (Wegovy/Ozempic)

Program	Details
Savings Card (with coverage)	Pay as low as $25/month; max savings ~$100/month
NovoCare Self-Pay	$499/month without insurance
Oral Wegovy	$149-299/month
Patient Assistance (PAP)	Free medication for income ≤200-400% FPL

Eli Lilly (Zepbound/Mounjaro)

Program	Details
Savings Card (with coverage)	Pay as low as $25/month
LillyDirect (vials)	$299/mo (2.5mg), $399/mo (5mg), $449/mo (7.5-15mg)
Lilly Cares (PAP)	Free medication for income ≤500% FPL

Key point about LillyDirect: it's available to anyone regardless of insurance status, including those with Medicare or Medicaid. The vials require you to draw your own injections (or your provider can show you how), but the cost savings are substantial.

Alternative Access Routes

If insurance won't cover and manufacturer programs don't work:

Telehealth Providers

Many telehealth platforms offer GLP-1 medications at competitive cash prices with included consultation. They often handle prior authorizations and can help navigate coverage.

Compounding (Where Available)

Tirzepatide can still be compounded since it remains in shortage. Compounded medications are typically $200-400/month. Note: compounded semaglutide is now restricted since the shortage resolved in February 2025.

International Options

Some patients purchase medications from international pharmacies at dramatically lower prices. US prices are roughly 10x higher than many countries. This involves legal gray areas and requires careful vetting of pharmacies.

Flexible Spending/HSA

If you have an FSA or HSA, GLP-1 medications (with prescription) are generally eligible expenses, reducing effective cost through tax savings.

What to Say to Your Insurer

When calling your insurance company:

• "I'd like to understand the specific criteria for prior authorization for [medication name]."
• "What documentation is required?"
• "Is there step therapy required? What alternatives must be tried first?"
• "If I'm denied, what is the appeal process and timeline?"
• "Is there a peer-to-peer review option?"

Document every call: date, time, representative name, and what was said. This creates a record if disputes arise.

The Long Game

Insurance coverage for GLP-1 medications is evolving rapidly. The trends:

• More employers adding coverage as they recognize cost savings from preventing obesity-related diseases
• Some states mandating coverage
• Medicare may eventually cover weight loss medications (legislative efforts ongoing)
• Prices likely to decrease as competition increases and generics eventually arrive

If you can't get coverage now, the landscape may improve. In the meantime, manufacturer programs and alternative routes may bridge the gap.

Key Takeaways

• Check your formulary first—know if coverage is even possible
• Prepare thoroughly for prior authorization with complete documentation
• Always appeal denials—success rates are meaningful and most people don't bother
• Use manufacturer programs—significant savings available for most patients
• Consider alternative routes if traditional coverage fails
• Be persistent—the system is designed to discourage you, but coverage is often achievable