How to Appeal Wegovy Coverage Denial

Wegovy (semaglutide) is a prescription drug approved by the FDA and indicated for weight loss and reducing the risk of certain cardiovascular events such as heart attacks. Wegovy is classed as a GLP-1 medication. GLP-1 is a key regulator of weight and blood sugar. Other GLP-1 meds include Ozempic, Mounjaro, Saxenda and Zepbound.

Despite its medical benefits, many insurance providers deny coverage for Wegovy due to policies that do not recognize weight loss medications as a medical necessity. If your insurance denies your Wegovy prescription, there are steps you can take to appeal the decision and alternative ways to access the medication without insurance.

Prior authorization for Wegovy

Before your insurance will cover Wegovy, many companies require prior authorization (PA). This process ensures the medication is medically necessary and aligns with the insurer’s coverage criteria. Your doctor typically handles the PA process by submitting relevant medical information to the insurance provider.

To determine if your insurance requires prior authorization for Wegovy, contact your insurer using the customer service phone number listed on your policy documents. Meeting the following FDA approved criteria may improve your chances of receiving authorization:

• Body Mass Index (BMI) of 27 kg/m² or higher with at least one weight-related health condition, such as high blood pressure (hypertension), type 2 diabetes or metabolic syndrome
• BMI of 30 kg/m² or higher without additional conditions
• Children aged 12 and older diagnosed with obesity
• Use of Wegovy in combination with a reduced-calorie diet and increased physical activity

Reasons for Wegovy coverage denial

Even if you meet the prior authorization criteria, insurance denial of Wegovy coverage can happen. Common reasons for denial include:

• Not medically necessary: The insurer may determine Wegovy is not essential for your condition
• Lack of evidence for first-line treatment: The claim may lack proof of step therapy that you’ve attempted other weight management interventions, such as lifestyle changes or alternative treatments
• Plan exclusions: Some insurance plans explicitly exclude weight-loss medications, categorizing them as non-essential or cosmetic

Health insurance companies often use these strategies to control costs, even when obesity-related conditions present significant health risks. While this can be frustrating, you have the right to appeal their decision.

How to appeal for Wegovy coverage

If your Wegovy claim is denied, and your insurance policy was created after March 2010, you can appeal the decision under protections established by the Affordable Care Act. Here’s how to navigate the appeals process effectively:

1. Understand the denial reason

Your insurer is required to provide a written denial letter, typically in the Explanation of Benefits (EOB) document. Understanding the specific reason for the denial helps you build a stronger case.

2. Gather supporting evidence

Collaborate with your doctor to create a compelling appeal that includes:

• A detailed explanation of your medical history and why Wegovy is necessary
• Evidence of previous weight-loss attempts, such as diet changes, exercise plans, use of other medications
• Documentation of any obesity-related complications, such as heart disease or type 2 diabetes and other medical conditions that Wegovy could help mitigate
• Sometimes, your doctor can help by speaking directly with the insurance company’s medical team. This is called a peer-to-peer review

3. Write your appeal letter

When crafting your appeal letter, consider these key points:

• Include the correct policy number and appeal department address
• State the denial reason and explicitly request approval for Wegovy
• Highlight how Wegovy aligns with your treatment goals and supports better health outcomes
• Reference clinical studies or medical guidelines that demonstrate Wegovy’s effectiveness

Novo Nordisk, the manufacturer of Wegovy, provides a sample appeal letters or additional information that can strengthen your case. This can be particularly useful if you are covered through an employer sponsored health plan. Submit your appeal within six months of receiving the denial notice and follow your insurer’s specific instructions for submission.

4. Follow Up

After submitting your appeal, contact your insurance provider regularly to check the status of your case. Persistence can help ensure your appeal receives timely attention.

How to get Wegovy without insurance

If you cannot obtain insurance coverage for Wegovy, there are still ways to access the medication:

• Discount programs and coupons – Websites like NowPatient provide discounts and coupons that can reduce the cost of Wegovy. These discounts are typically available for individuals paying out of pocket and are not valid with insurance copays
• Manufacturer savings programs – The Wegovy manufacturer, Novo Nordisk offers savings programs or support for eligible patients, from time to time. Visit their web-site for details on cost-reduction initiatives
• Pharmacy and online services – Pharmacies and telehealth platforms like NowPatient may offer competitive pricing for Wegovy prescriptions

Summary

Wegovy is an FDA-approved weight-loss medication that offers significant health benefits for individuals with obesity and related conditions. Despite this, insurance companies often deny coverage due to cost control measures and outdated views on weight-loss medications.

If your Wegovy coverage is denied, appealing the decision with a well-documented case can improve your chances of approval. For those unable to secure insurance coverage, exploring discount programs and manufacturer savings can help reduce out-of-pocket expenses.

Remember, always consult your healthcare provider to discuss the best options for accessing treatments

Sources

• Managing Weight with Wegovy – Wegovy
• Novo Nordisk – driving change to defeat serious chronic diseases