Wegovy (semaglutide) is an injectable medication that’s FDA approved for weight loss and other uses. Your health insurance may deny coverage for Wegovy, but you can still access it through an appeal or without insurance.

Wegovy is a brand-name medication that’s prescribed for weight loss in certain adults and children. It’s also used to reduce the risk of certain heart conditions in adults. Insurance companies may not classify weight loss medication as a medical treatment. It’s common to be denied coverage for a prescription of Wegovy. However, there are steps you can take to appeal an insurance denial.

Boxes of Wegovy 1.7-milligram (mg) and 1-mg dosesShare on Pinterest
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Prior authorization (PA) is a form certain insurance companies require to approve your prescription for coverage. A doctor will typically submit a PA letter to an insurance company to start the process of medication approval. To find out if you need PA, call the customer service number on your insurance documents.

To receive PA for Wegovy from your doctor, you’ll likely need to meet the requirements that the Food and Drug Administration (FDA) approved the medication for. These can include:

Often, meeting PA criteria isn’t enough for an insurance company to approve Wegovy. And if your insurance company requires PA to approve Wegovy, you won’t receive coverage for the medication without it.

Whether you receive coverage for Wegovy depends on what your insurance plan covers. For example, while Medicare covers the drug semaglutide (Ozempic) for diabetes treatment, it does not yet cover any medications for weight loss. This is often the same for commercial medical insurers.

Many insurers consider weight loss medication a cosmetic treatment rather than a medical one. Researchers and medical professionals often disagree as obesity leads to severe health problems such as high blood pressure and stroke.

Weight loss medications, including Wegovy, are often expensive. According to the American Medical Association, insurance companies aim to control costs using PAs. So doctors are often unable to predict the success of an approval for Wegovy. This is even if the medication is an important part of your treatment.

However, if your insurance company does cover weight loss medications, they may still deny a request for Wegovy. And even if your doctor determines Wegovy is medically necessary, an insurance company may still deny the medication.

If your insurance denies coverage for Wegovy and your plan was created after March 2010, you have the right to ask them to reconsider this decision through an appeal.

If starting or continuing treatment with Wegovy will improve your health, appealing an insurance denial is a good idea. According to research from 2021, around 49% of healthcare-related denial appeals are successful.

When considering an appeal, you should take the following steps:

Understand why you were denied

Identifying the reason for a denial will help form an effective appeal request. Your health insurance provider must respond with an explanation for the denial. This is the explanation of benefits.

Some common reasons for Wegovy denial include:

  • Not medically necessary: If an insurance company decides the prescription isn’t medically necessary, they will deny the claim. You can gather evidence with your doctor detailing why Wegovy is part of your treatment plan. This may include how much weight the medication has helped you lose already.
  • No attempt at first-line treatment: A claim lacking evidence that you have tried other treatments, such as lifestyle changes, may cause the insurance company to deny Wegovy. If you have tried other methods before Wegovy, include information about this in your appeal letter.
  • Plan exclusion: Some health insurance companies do not cover weight loss medication. In this instance, you will receive an automatic denial. You can appeal this by stating how receiving Wegovy now will save the insurers money in the future. View the Wegovy manufacturer website to see if your insurance covers Wegovy.

Write your appeal

There’s no one way to write an appeal letter, as each person will have a different circumstance. However, below are some tips to consider:

  • make sure your appeal department and policy number are correct
  • state the denial reason and your request
  • detail your weight loss history
  • explain why Wegovy is an effective medical treatment for obesity
  • mention the complications you may have an increased risk for without treatment, such as heart disease
  • use clinical studies in your argument

You can also take a look at a sample Wegovy appeal letter on the drug manufacturer website. You must submit your appeal within 6 months of receiving notice of your claim being denied. Be sure to follow your insurance company’s instructions for appeal. Once you submit the appeal letter, follow up with them.

You can collect a prescription for Wegovy from your local pharmacy or through online services.

Keep in mind, the cost of Wegovy is typically higher without insurance than with insurance. However, there are ways of managing the cost if you cannot receive insurance coverage.

For example, you can visit Optum Perks for Wegovy price estimates and use coupons from the site to save money. These coupons are not valid with insurance copays or benefits. You can also view the drug manufacturer website for information on savings.

Wegovy is a brand-name medication that’s FDA approved for weight loss and lowering certain heart condition risks. Insurance companies may deny coverage for Wegovy for different reasons. If this happens, there are steps you can take to appeal the insurance company’s decision. Gathering evidence that weight loss is important for your long-term health will increase the strength of an appeal letter.

If you cannot receive insurance coverage for Wegovy, there are other ways to lower the cost of your Wegovy prescription. These include using Optum Perks coupons and savings support from the drug manufacturer.

Disclaimer: Medical News Today has made every effort to make certain that all information is factually correct, comprehensive, and up to date. However, this article should not be used as a substitute for the knowledge and expertise of a licensed healthcare professional. You should always consult your doctor or another healthcare professional before taking any medication. The drug information contained herein is subject to change and is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. The absence of warnings or other information for a given drug does not indicate that the drug or drug combination is safe, effective, or appropriate for all patients or all specific uses.