Getting insurance to cover GLP-1 medications feels like navigating a maze designed to make you quit. Prior authorizations. Step therapy requirements. Denials with vague explanations. Most patients give up. Those who understand the system often succeed.
This guide walks you through the process—from choosing the right diagnosis codes to writing effective appeal letters.
Step 1: Understand What Your Plan Actually Covers
Before fighting for coverage, know what you're fighting for:
Check your formulary: Your plan's drug formulary lists which medications are covered and at what tier. GLP-1s are typically Tier 4 (specialty) or excluded entirely for weight loss indications.
Review exclusions: Many plans explicitly exclude "weight loss medications" or "anti-obesity agents." However, exclusions often don't apply to diabetes indications or cardiovascular risk reduction indications.
Call your insurer: Ask specifically: "Does my plan cover [medication name] for [specific indication]?" Get a reference number for the call.
Step 2: Choose the Right Diagnosis Code
The diagnosis code your physician uses significantly impacts coverage likelihood:
Obesity codes (E66.x): Often trigger automatic denials due to weight loss exclusions. E66.01 (Morbid obesity due to excess calories) is the most common—and most commonly denied.
The cardiovascular angle: After the SELECT trial, Wegovy has FDA approval for cardiovascular risk reduction. If you have established heart disease or multiple cardiovascular risk factors, using cardiovascular-related codes may bypass obesity exclusions.
Combination coding strategy: Pair the obesity code (E66.xx) with BMI code (Z68.xx) AND at least one comorbidity code. This paints a clinical picture of metabolic syndrome requiring treatment—not cosmetic weight loss.
Common supportive comorbidity codes:
- E78.5 — Hyperlipidemia (high cholesterol)
- G47.33 — Obstructive sleep apnea
- R73.03 — Prediabetes
- I10 — Essential hypertension
- K76.0 — Fatty liver disease
Step 3: Navigate Prior Authorization
Almost all GLP-1 coverage requires prior authorization (PA). Here's how to maximize approval chances:
Documentation requirements: Insurers typically require documentation of BMI ≥30 (or ≥27 with comorbidity), failed lifestyle interventions, relevant lab work, and list of current medications.
The lifestyle intervention trap: Many PAs require "documented failed lifestyle intervention." This doesn't mean you tried once—it means medical records showing physician-supervised diet/exercise attempts over 3-6 months. If you don't have this documentation, start building it now.
Step therapy requirements: Some plans require trying cheaper medications first (e.g., phentermine, contrave) before approving GLP-1s. This adds months to the process but may be required.
Use electronic prior auth: Services like CoverMyMeds streamline the PA process. Ask your prescriber if they use electronic PA systems—it significantly speeds approval timelines.
Step 4: Handle Denials and Appeals
Initial denials are common. Appeals often succeed.
Request the denial in writing: By law, insurers must provide written explanation of denials. This document reveals the specific reason—which tells you how to respond.
Common denial reasons and responses:
- "Not medically necessary" — Provide clinical documentation of obesity-related health conditions, failed prior treatments, and evidence-based guidelines supporting GLP-1 treatment.
- "Weight loss medications excluded" — If possible, reframe under cardiovascular indication. Or demonstrate that this exclusion shouldn't apply given your specific clinical circumstances.
- "Step therapy not completed" — Document why alternative medications are medically inappropriate (contraindications, prior failures, etc.) and request exception.
Peer-to-peer review: Request that your physician speak directly with the insurance company's medical director. These conversations often overturn denials when written appeals fail.
External appeal: If internal appeals fail, you have the right to external review by an independent third party. External appeals have meaningful success rates.
Step 5: Continuity of Care Strategies
Job transitions: If changing jobs, fill a 90-day supply before old insurance expires. This provides bridge coverage while navigating new plan's PA process.
Plan switching: Print your claims history showing prior GLP-1 use. "Continuity of care" provisions may help bypass step therapy on new plans if you have documented treatment history.
Annual re-authorization: Many plans require annual PA renewal. Mark your calendar 30-60 days before expiration to start the process early.
The Economic Reality
With the compounding crackdown and manufacturer direct programs, the economics are shifting:
- Brand-name cash pay: ~$350-550/month via LillyDirect or savings programs
- With good insurance: ~$25-200/month after PA approval
- The calculation: If your insurance battle takes 3 months of appeals, you might pay similar total cost to just using manufacturer programs during that time.
Insurance coverage is valuable for long-term cost reduction. But don't delay treatment indefinitely waiting for approval—manufacturer programs provide interim access.
When to Give Up on Insurance
Some situations make insurance coverage genuinely unattainable:
- Plan explicitly excludes all obesity treatments with no exception process
- You're on government insurance (Medicare/Medicaid) without applicable indication (until BALANCE coverage launches)
- Your plan requires 12+ months of step therapy you're not willing to complete
- Multiple appeals have been exhausted without success
In these cases, cash-pay through manufacturer programs is your pathway. Don't let insurance obstacles prevent you from accessing effective treatment.
Resources
Obesity Action Coalition: Provides insurance appeal letter templates and advocacy resources.
CoverMyMeds: Electronic PA platform that can accelerate the authorization process.
State insurance commissioner: If you believe your denial violates your policy or state regulations, file a complaint.
The system is designed to make you quit. Don't. Most coverage battles are won by patients who persist through the bureaucracy.