Trouble Getting Weight Loss Drugs Covered by Insurance? Here’s What To Know

An expert in-home caregiver misplaced her protection for Zepbound. She quickly realized getting it again was not simple.

Deborah Finley, 50, of Lodi, California, stated her weight began to fret her throughout the early days of covid. That’s when she seen plenty of the individuals who have been on ventilators or dying had one thing in frequent: weight problems.

“It was a scary time,” she stated. As a single mother, she was afraid “that I wouldn’t be right here for my daughter.”

Finley had been identified with sleep apnea and nonalcoholic fatty liver illness, and he or she was prediabetic. Her pulmonologist advised bariatric surgical procedure however couldn’t get Finley’s insurer to cowl it.

She exercised and watched what she ate, however she wasn’t losing a few pounds and her psychological well being suffered.

She remembers telling her physician: “Look, I’m at 223 kilos. I really feel like I’m hitting this wall. I don’t know what else I can do.” That’s when he advised Zepbound, a GLP-1 drug for weight problems.

Finley stated she nonetheless needed to put in plenty of work to get wholesome. However the drug helped. Her sleep apnea improved dramatically. She misplaced weight.

Then her insurance coverage plan stopped overlaying Zepbound for weight reduction on the finish of final 12 months. That’s turn out to be frequent as a result of GLP-1 medicine are costly for well being plans and the employers that pay for them.

“They began sending out notices to all of the sufferers,” Finley stated. “They usually stated: ‘Look, we’re pulling this treatment. We’re supplying you with 90 days’ discover to determine what you need to do.”

From 2025 to 2026, 12 million individuals have been on plans that dropped protection for Zepbound and 12 million had plans that dropped Wegovy, one other GLP-1, in response to analysis by GoodRx, an internet site that helps sufferers discover reductions on pharmaceuticals.

If you end up on this scenario, the following pointers will help. 

1. Learn the fantastic print on protection.

Whereas many plans don’t cowl GLP-1 medicine for weight reduction alone, they might make exceptions in case you have different situations.

That was Finley’s scenario. She realized that her insurer would cowl Zepbound if it was used to deal with obstructive sleep apnea, or MASH, a fatty liver illness. GLP-1s are additionally lined for individuals with Sort 2 diabetes.

You may work along with your medical doctors to display screen for qualifying situations, stated Caleb Alexander, a professor of epidemiology and medication on the Johns Hopkins Bloomberg College of Public Well being.

Undiagnosed diabetes, he stated, is “the probably situation that may permit for somebody to go from not being certified to being certified.”

Since Finley had sleep apnea and testing displaying that the drug helped, she realized it may nonetheless be lined with a previous authorization — that’s when you need to get approval out of your medical health insurance earlier than it’ll cowl a medical price.

Finley stated her doctor advised her a previous authorization was on file, however when she tried to refill her prescription, the pharmacist advised her Zepbound was denied.

2. File an attraction — and get some assist out of your physician.

Don’t quit in case your treatment is denied, stated Catherine Varney, the weight problems medication director for UVA Well being, the well being system affiliated with the College of Virginia in Charlottesville. Generally your insurer will relent on attraction, in case you make a superb case.

Finley made a number of irritating telephone calls and ultimately went digging via her on-line medical information.

“I needed to do my very own investigative work,” she stated.

These information confirmed that Zepbound was certainly denied. Her physician had utilized for prior authorization, however it didn’t undergo, as a result of her insurer stated there was not ample information to again up the request. In some way, her well being info, together with the sleep apnea testing outcomes, hadn’t made it to the suitable individuals.

Finley ultimately received her fingers on the 17-page report and received a little bit assist from ChatGPT to put in writing an attraction, displaying that the drug was obligatory for her primarily based on her prognosis and lined underneath her coverage.

This sort of attraction might be plenty of work. Fortunately, many medical doctors’ places of work will assist and know the way the system works, Alexander stated.

“I don’t assume that sufferers ought to be anticipated to navigate these waters on their very own,” he stated.

E-mail Signal-Up

Subscribe to KFF Well being Information’ free Morning Briefing.

3. Fastidiously doc your care.

Generally you might have to file a number of appeals if the primary one is unsuccessful, stated Tracy Zvenyach, the vice chairman for advocacy and analysis on the nonprofit Weight problems Motion Coalition, which receives monetary help from drugmakers together with Zepbound maker Eli Lilly and Wegovy producer Novo Nordisk.

Zvenyach additionally recommends preserving meticulous information. Some plans require one thing referred to as step remedy, that means sufferers must try to fail on different medicine or therapies earlier than getting lined for the one their physician needs them to take.

“Preserve a historical past of different meds you’ve taken so you’ll be able to present documentation for step remedy necessities,” she stated. “Doc dates of participation in any diet and bodily exercise program or membership.”

Finley filed an attraction on Feb. 4, and though she anticipated a listening to inside 90 days, it hadn’t been scheduled but as of mid-June.

She stated it’s been disturbing as a result of she hasn’t been capable of get new injections of Zepbound since mid-January.

4. Search for reductions in case you pay out-of-pocket.

The drugmakers that make Zepbound and Wegovy promote the medicines at a reduction to individuals who pay out-of-pocket as an alternative of utilizing insurance coverage. (Strive low cost websites like TrumpRx or GoodRx.)

Even with reductions, the medicine usually are not inexpensive for everybody. When you have a well being financial savings account or a versatile spending account, you should utilize it to pay for them with pretax {dollars}.

5. When you’re contemplating compounded GLP-1s on-line, look ahead to pink flags.

You might need seen advertisements for inexpensive off-brand weight problems medicine prescribed by on-line suppliers. These are compounded merchandise — that’s, made by specialised pharmacists as an alternative of a drug firm.

Compounded medicines are ready utilizing the identical energetic ingredient because the brand-name medicine. However they aren’t accredited by the Meals and Drug Administration.

Look out for high quality and issues of safety. Verify the Nationwide Affiliation of Boards of Pharmacy’s on-line pharmacy verification device. Be certain that the pharmacy getting ready your drug is licensed in your state. If it’s not, it will not be present process inspections or complying with different legal guidelines.

After stretching out her remaining provide of Zepbound so long as she may, Finley is taking a compounded model of the drug whereas she continues the insurance coverage appeals course of.

6. Be persistent. And keep in mind to breathe.

Being advised no by an insurer is exasperating. However Alexander stated you typically produce other choices.

“If any attraction that we make is unsuccessful, there are different therapies that we are able to use,” he stated — for instance medicine like Contrave, or a less expensive mixture of generic naltrexone and bupropion.

UVA Well being’s Varney, who has consulted for Eli Lilly, stated not to surrender on attempting to get GLP-1s lined. “Take a breath, however go proper again to it,” she stated, including that GLP-1s are superior to the older medicine available on the market.

Alexander stated he thinks weight problems medicine will ultimately turn out to be inexpensive — low cost even. Statins, that are used to deal with excessive ldl cholesterol, have been as soon as costly and arduous to get lined. Now, Alexander notes, they’re generic and infrequently price only a few bucks.

“I do know it’s arduous to think about,” he stated. “However there’ll come a day after we now not see these entry limitations for GLP-1s.”

Healthcare Helpline helps you navigate the well being system hurdles between you and excellent care. Ship us your difficult query and we might faucet a coverage sleuth to puzzle it out. Share your story. The crowdsourced mission is a joint manufacturing of NPR and KFF Well being Information.