How to appeal Wegovy insurance coverage denial

Why won’t my insurance cover Wegovy?

Often, just having a valid prescription isn’t enough for an insurance company to approve Wegovy. And if your insurance company requires prior authorization (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 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, often are expensive. According to the American Medical Association (AMA), 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, it still may deny a request for Wegovy. And even if your doctor determines Wegovy is medically necessary, an insurance company still may deny the medication.

Prior authorization for Wegovy

Prior authorization (PA) is a form that 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 for which the Food and Drug Administration (FDA) approved the medication. Some examples include:

• having a BMI of 27 kilograms per square meter (kg/m²) or more with at least one weight-related health condition, such as high blood pressure or type 2 diabetes
• having a BMI of at least 30 kg/m² or more
• being age 12 years or older (for children with obesity)
• using Wegovy as a part of a combination treatment that includes a low calorie diet

Medical perspective

How long should someone expect to wait to find out if their medication has been approved for prior authorization? How will they be notified?

“Most prior authorizations are completed in about 7 days for standard requests or 72 hours if urgent. Typically, you will be notified through your pharmacy, prescriber, or by a mailed letter or secure message from your insurer once the decision is made.”

— Olivia Taylor, PharmD, BCPS

Learn more about prior authorization here.

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

Steps to appeal a Wegovy coverage denial

If your insurance denies coverage for Wegovy and your plan was created after March 2010, you have the right to ask it 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 data from 2023, approximately 44% of insurance denials are successfully appealed.

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

Step 1: 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, it 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. Alternatively, you can include methods you used to try to lose weight in the past that were not successful, and how the increased weight is leading to other medical conditions.

• 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’s website to see if your insurance covers Wegovy.

Step 2: Write your appeal

An appeal letter can be written in different ways, as each person will have a different circumstance. However, here 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 or weight gain history.
• Explain why Wegovy is an effective medical treatment for obesity.
• Mention the complications for which you may have an increased risk 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’s website. You must submit your appeal within 6 months of receiving notice that your claim was denied. Be sure to follow your insurance company’s instructions for appeal. Once you submit the appeal letter, follow up with the insurance company.

How to get Wegovy without insurance

Here are a few things to consider when trying to get the best price for Wegovy without insurance:

• Comparing pharmacies: The cost of Wegovy may vary depending on which pharmacy you use, so it can help to compare prices across pharmacies to find the lowest price.
• Drug coupons: You may be able to find drug coupons on prescription discount websites that can reduce the cost of your medication. These coupons cannot be used with insurance copays or benefits, but the discounted price may be lower than what you would pay through insurance.
• Financial assistance: Some websites provide details about drug assistance programs, ways to make the most of your insurance coverage, and links to savings cards and other services. Two such websites are:
  • Medicine Assistance Tool
  • NeedyMeds

You can also view the drug manufacturer’s website for savings offers on Wegovy with or without insurance.

The takeaway

Wegovy is a brand-name medication that’s FDA-approved for weight loss and for other medical conditions and indications. Insurance companies may deny coverage for Wegovy for different reasons. If this happens, you can take steps to appeal the insurance company’s decision. 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, other options may reduce your cost of the drug.