glp1-insurance-coverage-guide
Purpose
This document explains how GLP-1 medication insurance coverage works in the US, including requirements for approval, how to check coverage, and the relationship between insurance companies, doctors, and prescriptions.
Key Question: Who Decides If You Get GLP-1s?
Short answer: Insurance dictates conditions, not just coverage.
It’s NOT simply “covered or not covered.” Even when a plan technically covers GLP-1s, the insurance company sets strict criteria that must be met before they’ll pay. The doctor prescribes, but the insurance company approves or denies based on their criteria.
The Decision Flow
Doctor prescribes GLP-1 ↓Pharmacy checks insurance ↓Insurance requires Prior Authorization (PA) ↓Doctor submits documentation to insurance ↓Insurance reviews against THEIR criteria ↓APPROVE or DENY ↓If denied → Appeal process (44% success rate)How Difficult Is It to Get GLP-1 Through Insurance?
Difficulty Rating: Moderate to High
| Factor | Difficulty |
|---|---|
| For Type 2 Diabetes | Easier - FDA-approved indication |
| For Weight Loss Only | Harder - often excluded or restricted |
| With Comorbidities | Moderate - depends on documentation |
| Meeting BMI threshold | Depends on your plan’s requirements |
Key stat: Over 88% of people face restrictions on GLP-1 coverage for weight loss.
Insurance Approval Requirements
Standard FDA Criteria
| Condition | BMI Requirement |
|---|---|
| Obesity | BMI ≥ 30 |
| Overweight + comorbidity | BMI ≥ 27 with qualifying condition |
| Children (12+) | 95th percentile or higher |
Qualifying Comorbidities
- Type 2 diabetes
- High blood pressure (hypertension)
- High cholesterol (dyslipidemia)
- Cardiovascular disease
- Sleep apnea
- Heart disease
BUT Insurance Often Has STRICTER Requirements
Example: Independent Health (2025)
- BMI ≥ 40 (not 30) required
- PLUS two obesity-related conditions
- OR BMI ≥ 30 with serious cardiovascular disease
- Zepbound preferred; Wegovy/Saxenda only if medical reason against Zepbound
Example: UnitedHealthcare
- Authorization periods: 4-6 months depending on drug
- Renewal requires showing 5% body weight loss
Common Additional Requirements
| Requirement | What It Means |
|---|---|
| Prior Authorization (PA) | Insurance must approve before pharmacy fills |
| Step Therapy | Must try cheaper drugs first and fail |
| Lifestyle Documentation | Proof of 3-6 month supervised diet/exercise |
| Letter of Medical Necessity | Doctor must justify why you need this specific drug |
| Renewal Criteria | Must show progress (typically 5% weight loss) to continue |
Drug-by-Drug Coverage Differences
Covered for Diabetes (Easier)
- Ozempic (semaglutide)
- Trulicity (dulaglutide)
- Rybelsus (oral semaglutide)
- Victoza (liraglutide)
Covered for Weight Loss (Harder)
- Wegovy (semaglutide 2.4mg) - FDA-approved for obesity
- Zepbound (tirzepatide) - FDA-approved for obesity
- Saxenda (liraglutide) - FDA-approved for obesity
Off-Label Use (Often NOT Covered)
- Ozempic for weight loss - Not FDA-approved for this, usually denied
- Mounjaro for weight loss - FDA-approved only for diabetes
Important: Even if a drug is FDA-approved for weight loss, your insurance may exclude it entirely or impose stricter criteria than FDA guidelines.
How to Check If Your Insurance Covers GLP-1s
Step 1: Check Your Formulary
- Log into your insurance portal
- Search for the drug formulary (drug list)
- Look for Wegovy, Zepbound, or the specific drug
- Note the tier (affects copay) and any restrictions noted
Step 2: Look for Coverage Restrictions
Common restrictions to look for:
- “Prior Authorization Required”
- “Step Therapy Required”
- “Quantity Limits”
- “Not Covered for Weight Loss”
- “Covered for Diabetes Only”
Step 3: Call Your Insurance
Ask specifically:
- “Is [drug name] covered under my plan?”
- “Is it covered for weight loss/obesity, or only diabetes?”
- “What are the prior authorization requirements?”
- “What BMI and documentation do I need?”
- “Is step therapy required?”
Step 4: Use Coverage Checker Tools
- Wegovy: NovoCare Coverage Check
- Ro Insurance Checker: Free service that calls insurance on your behalf
- GoodRx: Insurance coverage guides
The Prior Authorization Process
What Happens
- Doctor writes prescription
- Pharmacy submits to insurance
- Insurance flags PA requirement
- Doctor receives PA request
- Doctor submits documentation:
- BMI measurements
- Lab results (A1C, lipids, etc.)
- Diagnosis codes
- History of weight loss attempts
- Letter of medical necessity
- Insurance reviews (5-10 business days)
- Decision: Approve or Deny
Documentation Typically Required
- Current BMI calculation
- Weight history
- Comorbid conditions with diagnosis codes
- Previous weight loss attempts (diet, exercise programs)
- Previous medications tried (for step therapy)
- Lab results supporting medical necessity
- Personalized letter from doctor
Timeline
- Standard review: 5-10 business days
- Expedited review: Available if medically urgent
- Authorization period: 4-6 months (varies by drug/insurer)
If You’re Denied
Denial Reasons
| Reason | What It Means |
|---|---|
| ”Not medically necessary” | Insurance doesn’t think you need it |
| ”Step therapy required” | Must try cheaper drugs first |
| ”Documentation insufficient” | Missing BMI, labs, or history |
| ”Excluded benefit” | Your plan doesn’t cover weight loss drugs at all |
| ”Criteria not met” | You don’t meet their BMI/comorbidity requirements |
Appeal Success Rate: ~44%
Key insight: Fewer than 1% of denials are appealed, but 44% of appeals succeed.
How to Appeal
- Review denial letter - Identify what’s missing
- Get detailed Letter of Medical Necessity - Personalized to your case
- Include all documentation - BMI, labs, comorbidities, weight history
- Demonstrate lifestyle efforts - Supervised programs, documented diet/exercise
- Cite clinical evidence - Connect your profile to research
- Submit within deadline - Usually 15-30 days
- Keep appealing - You have multiple appeal rights
Appeal Resources
- Claimable - GLP-1 appeal assistance
- Honest Care - Wegovy/Zepbound denial help
- Counterforce Health - Evidence-based appeal guides
Medicare & Medicaid
Medicare
- Current: Does NOT cover GLP-1s for weight loss alone
- Covered if: Prescribed for diabetes OR cardiovascular risk reduction (Wegovy)
- Changing: Trump administration deal expected to expand coverage to obesity + comorbidities
- Timeline: Part D coverage expected ~July 2026
Medicaid
- Only 13 state programs cover GLP-1s for obesity (as of August 2024)
- All require prior authorization
- Most have strict BMI requirements
- BALANCE Model: Expanded coverage expected May 2026
Summary: The Insurance Control Model
| Question | Answer |
|---|---|
| Does insurance dictate when GLP-1 can be prescribed? | Yes - through prior authorization requirements |
| Can a doctor just prescribe it? | Doctor can prescribe, but insurance can refuse to pay |
| Is it “covered or not”? | No - coverage comes with CONDITIONS that must be met |
| Who decides if conditions are met? | Insurance company reviews documentation |
| Can you appeal? | Yes, 44% success rate |
| Is it easy to get? | Moderate to difficult depending on plan and your health profile |
The Reality
- Your plan may “cover” GLP-1s but with strict criteria
- Insurance sets BMI thresholds, comorbidity requirements, step therapy
- Doctor must document everything and submit for approval
- Insurance reviews and decides - not the doctor
- Even if approved, you may need to show progress to continue
- 88%+ face coverage restrictions for weight loss indication