Coverage by Insurer
The Reality of GLP-1 Coverage in 2026
Insurance coverage for weight loss GLP-1s remains fragmented and restrictive. While most major insurers cover Ozempic and Mounjaro for diabetes, coverage for obesity (Wegovy, Zepbound) varies wildly by plan, employer, and state.
⚠️ Important: Your Plan May Differ
Even within the same insurer, coverage depends on whether you have an employer plan, marketplace plan, or individual plan. Always check your specific formulary.
| Insurer | Wegovy (Weight Loss) | Zepbound (Weight Loss) | Notes |
|---|---|---|---|
| UnitedHealthcare | Plan-dependent | OSA pathway | Coverage available through sleep apnea diagnosis |
| Cigna | Tier 4 + PA | Formulary | New $200/mo cap option in some plans |
| Aetna | Employer plans | Employer plans | Requires 6-mo weight management documentation |
| Blue Cross Blue Shield | State-dependent | State-dependent | Highly variable; some states exclude entirely |
| CVS Caremark | Preferred | Removed July '25 | Zepbound removed; exception process available |
| Kaiser | Select plans | Select plans | Integrated care model; coverage expanding |
Medicare Coverage 2026
🎉 Big News NEW JULY 2026
The BALANCE Model launches in July 2026, offering Medicare beneficiaries GLP-1 access at negotiated prices. This is the first time Medicare will cover these drugs for weight loss.
Who Qualifies for Medicare BALANCE Model?
Eligibility is based on BMI and existing health conditions:
- BMI ≥27 with prediabetes or cardiovascular disease history
- BMI ≥30 with heart failure, hypertension, or chronic kidney disease
- BMI ≥35 (no additional conditions required)
💡 How to Prepare
Talk to your doctor now about documenting your BMI and any qualifying conditions. Having this documentation ready will speed up enrollment when the program launches.
Why You Were Denied
Common Denial Reasons (And What They Really Mean)
🚫 "Not Medically Necessary"
This usually means your documentation didn't show BMI ≥30 (or ≥27 with comorbidities). Solution: Submit lab work, height/weight measurements, and documented comorbidities like hypertension or sleep apnea.
🚫 "Step Therapy Required"
Your insurer wants you to try cheaper options first (like phentermine or orlistat). Solution: Document that you've tried these OR submit a step therapy exception explaining why they're inappropriate for you.
🚫 "Prior Authorization Not Obtained"
Your doctor prescribed without getting pre-approval. Solution: File retroactive PA request or have doctor submit new PA with proper documentation.
🚫 "Excluded from Formulary"
Your plan simply doesn't cover this medication. Solution: Request a formulary exception citing medical necessity, or consider compounded alternatives.
How to Appeal (And Win)
The 65% Success Rate Most People Miss
Here's the shocking truth: 85% of people who are denied GLP-1 coverage never appeal—even though appeals succeed more than 65% of the time. Don't leave money on the table.
- Get Your Denial Letter Request the written denial with specific reason codes. You have legal right to this document.
- Gather Your Documentation BMI records, comorbidity diagnoses, previous weight loss attempts, doctor's letter of medical necessity.
- File Internal Appeal (Level 1) Submit within 180 days. Include all documentation and a cover letter addressing denial reason.
- Request External Review (Level 2) If internal appeal fails, you can request independent review. This is decided by a third party, not your insurer.
- Consider Professional Help Services like Counterforce Health and Honest Care specialize in GLP-1 appeals with 65%+ success rates.
✓ Pro Tip: Use Insurance Language
Reference your plan's own coverage criteria in your appeal. If they require BMI ≥30, explicitly state "Patient meets criteria with documented BMI of 32.4"
No Insurance? Your Options
Self-Pay Programs from Manufacturers
Both Novo Nordisk and Eli Lilly offer significant discounts for cash-pay patients:
| Program | Medication | Monthly Cost | Details |
|---|---|---|---|
| NovoCare Self-Pay | Wegovy (injection) | $349/mo | $199 intro for first 2 fills |
| NovoCare Self-Pay | Wegovy (NEW pill) | $149-299/mo | Oral semaglutide option |
| LillyDirect | Zepbound (vials) | $299-449/mo | Dose-dependent pricing |
Compounded Alternatives
Compounded semaglutide and tirzepatide from telehealth providers offer significant savings—typically $149-399/month with no insurance needed.
⚠️ Important Disclaimer
Compounded GLP-1 medications are NOT FDA-approved. They are prepared by state-licensed compounding pharmacies. Quality and safety can vary. Always use providers that work with 503B outsourcing facilities when possible.
Compare All Your Options
See real prices from 15+ providers, including manufacturer programs and telehealth options.
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