Insurance basics: coverage, prior authorization and appeals

Insurance is where most beginners hit the first wall, and the wall is different depending on the indication the prescription is written for. This page is a map of the US system as it applies to the four brand products. Compounded products are not covered by insurance and no manufacturer program applies to them.

The indication decides the rules

The same molecule is treated differently depending on which label it is prescribed under.

• Type 2 diabetes (Ozempic, Mounjaro): usually a covered category. Plans may still require prior authorization or step therapy (trying metformin first, for example), but the benefit exists.
• Weight management (Wegovy, Zepbound): a category many plans exclude outright. When a plan does cover it, a prior authorization is almost universal.
• Other indications on the same labels: Wegovy's cardiovascular indication and Zepbound's obstructive sleep apnea indication are separate medical indications with their own coverage logic; a plan that excludes weight-loss drugs may still cover the drug for those uses.

Ask your plan, in writing, which indications it covers each product for. Your prescriber's diagnosis code on the prescription needs to match.

What a prior authorization usually asks

A prior authorization (PA) is the plan asking the prescriber to document that you meet its criteria before it pays. For weight-management drugs the criteria commonly mirror the label population: BMI 30 or higher, or 27 or higher with a named weight-related condition (see who the labels say they are for). Plans often add requirements the label does not have: a documented period of lifestyle intervention, participation in a program, a recorded baseline weight, and later a re-authorization that asks for a percentage of weight lost. The network's Tools and Templates site has a PA checklist your prescriber's office can work from. Bring your weight history and any program records to the first visit; they shorten the PA.

Employer and marketplace plans

Coverage is a plan-design choice. Two people with the same insurer can have opposite answers because their employers bought different formularies. The document that answers the question is the plan's formulary (drug list) plus its PA criteria, both of which you are entitled to see. If the drug is excluded, the useful conversation is with HR about the next plan year, not with the insurer's phone line. If it is covered with a PA, the useful conversation is with the prescriber's office about the documentation.

Medicare

Medicare Part D was built on the Medicaid statute's list of drug classes a program may exclude, and "agents when used for anorexia, weight loss, or weight gain" is on that list (42 U.S.C. 1396r-8(d)(2)(A)). That is why Part D plans do not cover Wegovy or Zepbound for weight loss. The exclusion is tied to the use, not the molecule: Part D plans may cover Ozempic and Mounjaro for type 2 diabetes, and Wegovy for its cardiovascular risk-reduction indication in adults with established cardiovascular disease and obesity or overweight (Wegovy label section 1). Manufacturer savings cards cannot be used with Medicare. Any federal demonstration or bridge program for GLP-1s changes fast; the Pricing Index tracks the current state with dates rather than this page.

Medicaid

Each state decides whether its Medicaid program covers anti-obesity medicines, and the answer changes year to year. The network's GLP-1 Access by State site keeps a state-by-state page with the current status and the state's own source.

Savings cards, briefly

Lilly and Novo Nordisk savings cards reduce the copay for people with commercial insurance. They have a monthly maximum benefit, an annual cap, and terms that change. They are not available to anyone with government insurance, and they do not exist for compounded products. Cost basics covers where they fit.

Appeals, in order

A denial is not an exclusion; a denial can be appealed. For non-grandfathered plans, federal rules give you an internal appeal with the plan and then an independent external review (45 CFR 147.136). The steps:

1. Get the denial in writing with the reason code.
2. Ask the prescriber's office to submit a letter of medical necessity addressing that exact reason, with the label wording and your documented history attached.
3. If the internal appeal fails, request external review within the deadline on the denial letter.
4. Keep copies of everything and note every call.

The Tools and Templates site has an appeal letter template. If the plan simply excludes the category, none of this applies, and the honest answer is the self-pay routes on the cost basics page.