Access · Insurance

The insurance door: coverage, prior authorisation and appeals

Insurance is the largest single variable in what a GLP-1 costs you, and it is the one this site's price database cannot tell you anything about. If a plan covers the approved product, the cash comparisons everywhere else on this site may be irrelevant to your decision. This is how to find out.

Check this before you compare cash prices

Every figure in this database is a cash price. If your plan covers an approved GLP-1, your copay is the number that matters, and it can be far below any cash price here. Establishing coverage is therefore the first step, not a later one.

Coverage for anti-obesity medication varies by employer group as much as by insurer, so a colleague's answer at a different company tells you nothing about yours. Ask your own plan.

The prior authorisation and appeal sequence

1. Find out what your plan actually covers

Ask your insurer directly whether anti-obesity medications are a covered benefit under your specific plan, and get the answer in writing. Coverage varies by employer group, not just by insurer.

2. Get the prior authorisation criteria in writing

Request the plan's published criteria for the specific drug. These usually specify a BMI threshold, sometimes a comorbidity requirement, and often a documented trial of another approach.

3. Assemble the documentation the criteria name

Weight and BMI history, comorbid diagnoses, prior weight-management attempts with dates, and any contraindications to alternatives. Match the criteria item by item rather than sending a general letter.

4. Submit and record the reference number

Have the prescriber's office submit the prior authorisation and record the reference number, submission date and the name of who took it.

5. If denied, request the specific reason and the appeal deadline

A denial must state a reason. Get it in writing along with the internal appeal deadline, which is often short.

6. File the internal appeal against the stated reason

Address the specific reason for denial with the specific documentation that answers it. A letter of medical necessity from the prescriber, written against the plan's own criteria, is the core document.

7. Escalate to external review if the internal appeal fails

Most plans are subject to an independent external review process. The denial letter must tell you how to request it and by when.

Why denials happen, and what answers them

Most denials are not judgements about whether the medication would help. They are findings that the submitted documentation did not match the plan's written criteria. The remedy is correspondingly mechanical: get the criteria, and answer them item by item with dated documentation.

The most common gaps are an undocumented history of prior weight-management attempts, a comorbidity that exists in the chart but was not cited, and a BMI recorded at the wrong point in time. All three are fixable on appeal.

Compounded products and insurance

Compounded GLP-1s are generally not covered, because they are not FDA-approved products. Paying cash for a compounded product is not an alternative route to coverage — it is a different transaction entirely, and it does not build any record that helps a future authorisation for the approved product.

HSA and FSA

A prescribed medication is generally an eligible expense for health savings and flexible spending accounts, which effectively discounts it by your marginal tax rate. This applies to cash-pay prescriptions too. Keep the prescription record and the receipts; substantiation requirements are real.

Questions

Does insurance cover GLP-1s for weight loss?

It depends on the specific plan, and it varies by employer group as much as by insurer. Ask your own plan whether anti-obesity medications are a covered benefit, and get the answer in writing.

What do I do if my prior authorisation is denied?

Get the specific reason for denial and the internal appeal deadline in writing, then appeal against that specific reason with documentation that matches the plan's published criteria item by item. If the internal appeal fails, most plans are subject to independent external review.

Will insurance cover compounded tirzepatide or semaglutide?

Generally no, because compounded products are not FDA-approved. Cash payment for a compounded product does not build a record toward a future authorisation for the approved one.