Top 5 Reasons Insurance Denies GLP-1 Medications (and What You Can Do About It)
Top 5 Reasons Insurance Denies GLP-1 Medications (and What You Can Do About It)
Top 5 Reasons Insurance Denies GLP-1 Medications (and What You Can Do About It)
If your insurance company has denied coverage for a GLP-1 medication such as Ozempic, Wegovy, or Mounjaro, you’re not alone. Every week, thousands of patients face the same frustrating letter: “Your request has been denied.”
But here’s the truth: most denials are not the end of the road. They usually happen because of specific, predictable reasons―and knowing these reasons can help you take the right next step.
At AppealBridge, we see the same denial patterns over and over. Below, we break down the five most common reasons insurers deny GLP-1 medications―and what you can do if it happens to you.
1. Not Meeting “Medical Necessity” Criteria
Insurers often require proof that the medication is medically necessary. This may include:
- A diagnosis of type 2 diabetes or obesity (BMI ≥ 30, or BMI ≥ 27 with related conditions).
- Documentation of prior weight-loss attempts.
- Evidence that the medication is part of a broader treatment plan.
What you can do: Ask your doctor to provide detailed medical records, including your BMI, lab results, and history of other treatments. The more evidence you submit, the harder it is for the insurer to claim the drug is “unnecessary.”
2. Step Therapy Requirements
Many insurers use “step therapy,” meaning you must try (and fail) cheaper alternatives before they will approve a GLP-1. For example, they may want proof that you attempted metformin or older weight-loss medications first.
What you can do: Work with your doctor to document which medications you’ve already tried, including why they didn’t work or caused side effects. This can strengthen your appeal.
3. Insufficient Documentation from Your Provider
Sometimes the denial isn’t about you―it’s about paperwork. If your doctor’s office left out information or didn’t use the insurer’s required form, the request may be rejected automatically.
What you can do: Double-check the denial letter. If it says “missing documentation,” ask your provider to resubmit with the required details.
4. Coverage Exclusions in Your Plan
Some insurance plans exclude GLP-1 medications entirely, especially if prescribed for weight loss rather than diabetes. If your plan has this exclusion, the denial will be automatic.
What you can do: Review your plan documents carefully. Even if exclusions exist, you may still have options to appeal if your doctor can show the drug is essential for treating diabetes or another covered condition.
5. Cost Concerns and Tier Placement
GLP-1 medications are expensive―sometimes more than $1,000 per month. Insurers place them on the highest formulary tiers, making approval harder. Sometimes the denial is simply about cost containment.
What you can do: File an appeal with strong clinical evidence. Insurers are more likely to approve if you can show the long-term benefits of GLP-1s (such as preventing hospitalizations or complications), which may actually save money overall.
What to Do if You’ve Been Denied
A denial doesn’t mean the end of your journey. Most patients win approval after filing a strong, well-supported appeal. That’s where we come in.
At AppealBridge, we help patients and providers navigate the appeal process step by step. Instead of trying to figure out the right language or format on your own, we guide you through what to include and how to present your case.
You don’t have to accept “no” as the final answer.
Final Thoughts
Insurance denials for GLP-1 medications are frustrating, but they follow predictable patterns. By understanding the reasons―and taking action―you can increase your chances of approval.
If you’ve been denied coverage for Ozempic, Wegovy, or another GLP-1, AppealBridge is here to help you build the strongest possible appeal.