Zepbound appeals explainedWegovy appeals explainedOzempic appeals explainedMounjaro appeals explainedZepbound prior authorization denialsWegovy prior authorization denialsMounjaro prior authorization denialsOzempic prior authorization denialsWeight loss plan exclusions explainedStep therapy denials explainedPricingFAQ
Your plan’s formulary is the list of medications covered by your health plan. A formulary is generally established by the pharmacy benefit manager (PBM), a third-party entity contracted by your insurance provider for managing medication coverage. Typically, decisions regarding formulary inclusion are guided by a pharmacy and therapeutics (P&T) committee.
Insurance providers may opt to exclude more expensive medications from their formulary as a strategy to manage and reduce costs. Given that GLP-1 medications like Zepbound lack generic alternatives, most insurers will include less pricey options such as Qsymia, phentermine, or Contrave either on their formulary or as preferred medications for step therapy. For more information on step therapy, check out our blog article on Step Therapy Denials.
Common alternative medications to Zepbound may include:
• Contrave
• Orlistat (Xenical)
• Phentermine (Adipex-P)
• Plenity
• Qsymia
• Saxenda
PBMs rely on the advice of a pharmacy and therapeutics committee to recommend which drugs should be included in the formulary and their coverage order. However, the final decision on included drugs rests with the PBM. If your coverage request is denied because the medication isn't on your plan's formulary, it indicates that the PBM has chosen not to include it. You may challenge this decision by having your provider submit a Formulary Exception Request or by submitting a well-crafted appeal.
Alternatively, if your employer has chosen specifically not to include the medication or drug class in your plan, this means that the medication or category of medications is an exclusion under your plan. While this kind of appeal is not impossible to win, it can be quite challenging to overturn since the decision not to provide coverage was made by your employer. For more information on exclusion denials, see our blog post on Weight Loss Plan Exclusion Denials, Explained.
To identify the reason for your denial, start by reviewing your official denial letter. This will have been sent by your insurance company via email or traditional mail. Here are examples of statements in denial letters that could suggest your requested medication is not covered by your insurance formulary:
If you can’t find your denial letter (or have not received it yet), another option is to contact your insurance provider directly to ask about the reason for the denial. During the call, it can be helpful to also inquire about your appeal options and the preferred method for submitting an appeal under your plan. Remember, you have the legal right to appeal an insurance denial, and you can choose to submit your appeal independently or with assistance from your healthcare provider.
If you were denied medication coverage, whatever the reason, we recommend appealing. If you’re handling your Zepbound appeal on your own, consider letting Honest Care do the work for you. We offer free, effective, and professionally-written appeal letters with just a few edits required for personalization. If you’d like a more hands-off experience, we also offer pricing packages for full customization. Take the assessment here.
An appeal is a written request to your health insurance provider to revisit your coverage denial for a medication or therapy. Initially, the denial for coverage of a GLP-1 medication is typically automated. During the appeal process, however, a human reviewer evaluates your coverage request and makes a decision based on your case. You have six months after the denial notice to submit an appeal. When your insurance denies coverage, they are required to provide an explanation detailing the reasons for the denial and instructions on how and where to submit an appeal. Appeals are commonly required to be submitted via mail or fax. Visit healthcare.gov for general information on appeals.
If Zepbound is not part of your plan’s formulary, your PBM probably has a tiered list of medications that they prefer to Zepbound. To increase your chances of overturning the denial, advocate for why these "preferred" medications may not be suitable for you.
When appealing a denial for a weight loss medication like Zepbound, insurance providers often prefer that you have previously attempted weight loss through traditional methods such as diet and exercise. Many individuals grappling with weight gain have tried strategies like calorie counting and increased physical activity. Document any specific diets you've followed, such as Atkins or the Mediterranean Diet. If you've used a paid program like Weight Watchers or Noom, gather receipts or check-in documentation. Include details like dates of participation, duration, and the effectiveness of the program. If you haven't used a specific program, highlight efforts like consulting a nutritionist, maintaining an active gym membership, or working with a personal trainer to lose weight without medication.
Because formulary decisions prioritize cost, it's helpful to highlight potential future expenses if your condition goes untreated. Managing weight-related conditions like heart disease, stroke, Type 2 diabetes, and certain cancers can be significantly more costly than covering your requested medication upfront.
Make sure to carefully review your denial letter (or contact your insurance company) to find out the preferred method for submitting your appeal. Some plans may require appeals to be sent by regular mail, while others may accept electronic submissions. Your denial letter will provide instructions on where to send your appeal. Remember to include your Member ID and claim number in the header of your appeal.
For more information on appeals for specific medications, check out our posts on appeals for Wegovy, Zepbound, Mounjaro, and Ozempic.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments, because access to great healthcare is a human right.
Insurance companies purposely make this process convoluted and difficult to understand in order to deter decision challenges and protect their bottom line. That’s where we come in. We’re bridging the gap between insured individuals and their access to needed medications by creating a free customized insurance appeal letter. We’ll do all the hard work for you - you just need to include a few small edits, then you can send your appeal letter to your insurance provider through their outlined appeal process.
We believe every insurance denial should be appealed and every patient should fight for access to the best treatments we’ve made generating a strong appeal letter free.
We also offer paid services to access our team of GLP-1 experts. If you are not satisfied with our team's services, email our support team at support@findhonestcare.com and we will be happy to remedy any issues. You can also request a refund within 60 days of purchase of our services so long as your appeal hasn't been submitted to your insurance. Once our appeal packet has been submitted to your insurance, we will no longer issue refunds. Refunds are processed to the original payment method within 5 to 10 business days.
We help patients fight insurance coverage denials so they can get access to the medications and treatments they deserve. We currently specialize in insurance coverage denials for Ozempic, Mounjaro, Wegovy and Zepbound.
If you are denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, Honest Care can help fight your denial by submitting an ‘appeal’ to your insurance. An appeal is a formal request to your health insurance company to overturn their denial and grant coverage on your behalf. An appeal generally consists of a formal letter, addressed to your insurance, explaining why a medication should be covered on your behalf and why your insurance’s initial denial should be overturned.
You have the right to appeal to your insurance’s coverage denial. Honest Care simplifies the appeals process by writing an appeal letter and supporting documents on your behalf making your best arguments for medication coverage, following your completion of our proprietary GLP-1 denial assessment.
If your insurance denied coverage for Ozempic, Mounjaro, Wegovy or Zepbound, you have the legal right to ask your insurance to reconsider the coverage denial by sending an ‘appeal’. Unfortunately coverage denials too often go unchallenged. A study from September 2023 found that 69% of people who were denied coverage by their insurance didn’t know they could appeal, and 85% of people never tried to appeal.
We believe it always makes sense to appeal. Here is why:
Appeals work: According to a study analyzing data from several U.S. states, patients who appealed directly to their insurance provider (an internal appeal) experienced a success rate between 39-59%.
Denials are often issued by mistake: A computer almost always makes the initial decision to deny medication coverage. This results in denials that don’t actually consider your personal health situation or denials made by mistake. In the case of Ozempic, Mounjaro, Wegovy and Zepbound, incorrectly entered information about your BMI, labs including A1c, your health conditions and diagnoses, your medication history and current medication use can all lead to an automatic denial. When you appeal, your information is reviewed by a real person.
Doctors review appeals, not computers: Having a doctor consider your unique circumstances makes submitting an appeal a powerful process for overturning denials getting covered.
You deserve the best care: You have the legal right to fight the treatment you need. As a part of the Affordable Care Act, all health insurance plans are required to allow their members to appeal their coverage decisions. This spans all insurance coverage - whether you are insured through your employer, purchased an insurance plan through your state marketplace, or are insured through a government program like Medicare or Medicaid.
We currently offer appeal services for Ozempic, Mounjaro, Wegovy and Zepbound. After purchasing Honest Care and completing your online denial assessment, you can expect to receive your appeal letter within 2 business days.
1. Online denial assessment: Complete the online assessment at your convenience that gather all the necessary appeal evidence for your insurance. The assessment reviews your medication history, including any GLP-1s, weight loss or diabetes medications you have taken, your health conditions and diagnoses, your past weight loss, diet and exercise attempts, and details on your insurance coverage and denial.
2. Case evaluation & appeal strategy: One of our dedicated appeal specialist will review your assessment and insurance denial and identify your best appeal arguments for coverage. This will include an evaluation of your medication history, medical diagnoses, weight loss attempts and clinical research studies that strength your appeal case.
3. Appeal letter & supporting documents: Your assigned appeal writer will compose a professional appeal letter addressing your denial reason and detailing your case for coverage. We’ll create a supporting evidence report that further justifies your appeal letter, to send your insurance along with your appeal.
4. Specialist Consultation & Support: After you receive and review your appeal letter & evidence, your dedicated appeal specialist will be available to answer your questions. They will be available to make updates to your appeal, if required. You will also have the option to schedule a phone or video call at a time of your convenience to you speak to your dedicated appeal specialist.
5. Send your appeal: You can submit your appeal yourself or have your doctor submit your appeal on your behalf. Most insurance companies accept appeals by mail or fax. Instructions on how to submitted appeal will be included within the written explanation on why you initially denied medication coverage, sent at the time at you were denied.
An insurance appeal is a formal request you make to your insurance company, asking them to reconsider a decision about your claim. This could be when they've denied your claim, not paid enough, or made a decision you disagree with. The appeal is your chance to argue your case, showing them why their decision should be different. It involves submitting a well-structured letter, along with any supporting evidence like medical records or repair estimates, to make your case stronger.
An insurance appeal letter is your way of asking the insurance company to reevaluate a decision, such as a denied claim. It's essentially your argument in writing, explaining why you believe their decision should be different. This is a common document patients can use to advocate for themselves with their insurance to cover their medical costs even prior to being denied for a treatment.
This letter will include your policy details, specific decision you disagree with, and provide solid reasons and evidence (like weight loss efforts, past and present medications, labs, receipts etc) for your appeal. The letter should be clear, concise, and respectful, ending with a specific request for what you want your insurance to do.
You can submit an appeal letter directly to your insurance or through your health care provider as part of your insurance appeal process.
Insurance supporting evidence is the documentation or information you provide to back up your claim or appeal with your insurance company. It's the proof that supports your case, like medical history, diet and exercise efforts, medication history, or relevant medical studies. This evidence is crucial because it shows the insurance company why they should approve your claim or reconsider a decision they've made.
We provide 3 types of supporting insurance evidence.
(1) Appeal Evidence - is the information you provide when you disagree with your insurer's decision about a claim or coverage. This could include detailed medical records, letters from your doctor explaining the necessity of a treatment, or information about how a treatment is standard for your condition. This evidence is crucial for challenging a denial or underpayment of a claim. Our role is to help you gather and present this evidence effectively, ensuring it clearly supports your need for the treatment or service claimed.
(2) Prior Authorization Evidence - is required when your health plan needs you to get approval before it covers certain medications or procedures. This evidence typically includes medical records, lab results, and a detailed rationale about why this specific medication or procedure is necessary for your condition. Our service involves assisting you in compiling comprehensive and relevant documentation to justify the medical necessity, aiming to secure approval from your insurance company for the required treatment.
(3) Step Therapy Exclusion Evidence - is used when you need to bypass the 'step therapy' protocol of your insurance plan. This protocol usually requires trying less expensive treatments before more costly ones are approved. Exclusion evidence might consist of medical records showing previous treatment attempts and failures, clinical data indicating why standard treatments are unsuitable or harmful for you, and detailed explanations about the necessity of the specific, often more expensive, treatment. We help you collect and organize this evidence to make a compelling case to your insurer that the standard step therapy process is not appropriate for your situation, thereby aiming for an exemption.
Working with your regular doctor can increase your chance of insurance coverage in several ways, including:
Yes - your Honest Care Report can be submitted to any doctor, including doctors working with online, telehealth-based GLP-1 clinics. Taking the Honest Care Assessment before engaging with a telehealth services presents several advantages, including helping you save money.
By using Honest Care before engaging with a telehealth company, you’ll find out how likely you are to get a GLP-1 prescription and will receive guidance on any recommended steps to take before your GLP-1 appointment. This can save you money by avoiding paying subscription fees until you’re fully prepared for your telehealth appointment.
There are nearly 10 GLP-1 medications available in the United States. Currently three of those medications, Zepbound®, Wegovy® and Saxenda®, are FDA-indicated for weight-loss assistance. The FDA indicates that people with a BMI ≥ 30 kg/m2 OR people with a BMI ≥ 27 kg/m2 who have been diagnosed with at least 1 weight-related condition are eligible for GLP-1s.
All other GLP-1 medications, including Ozempic® and Mounjaro®, are currently FDA-indicated for people diagnosed with Type 2 diabetes.
While FDA-guidelines are critical for understanding GLP-1 eligibility, there are a number of other factors to consider for determining GLP-1 eligibility.
Additional eligibility criteria that Honest Care takes into account include:
Prior Authorization (PA) is a process run by insurance plans to determine how necessary a medication is. Most insurance plans require Prior Authorization (PA) before approving coverage for GLP-1s.
After your GLP-1 prescription is written, your insurance plan will notify your doctor if a PA is required and ask your doctor for additional documentation on why your medication is necessary.
If a PA is required, your insurance plan will ask your doctor to submit detailed information on your diet and exercise history, your past weight loss attempts, weight loss medications you previously tried, and any unique challenges that you face that make a GLP-1 medically necessary.
The Honest Care Report includes evidence requested by most insurance plans and can be submitted to your insurance during the PA process. During your appointment, your doctor can attach your Honest Care Report to your health record so it is submitted as supporting evidence to your insurance if Prior Authorization is required.
