GLP-1 medications like Zepbound, Wegovy, and Mounjaro have been game-changers for weight loss, but the biggest roadblock remains: insurance coverage. Some policies cover them with a prior authorization (PA), while others exclude obesity treatment entirely. If you’ve hit a denial, don’t assume that’s the end of the road.
Your path depends on your insurance situation, so let’s break down your options:
Track 1: Insurance covers GLP-1s, but requires a prior authorization (PA).
Track 2: Insurance excludes obesity treatment but may cover the drug for another condition.
Track 3: You’re on Medicare or Medicaid, which rarely covers obesity medications.
Track 4: You don’t have insurance at all, cash-pay vials might be your best bet.
If you are on track 1 or 2, you will want to familiarize yourself with the various manufacture savings card programs (what's this) available for both Zepbound and Wegovy (both programs require the participant to possess commercial insurance, and exclude Medicare and Medicaid participants by law).
Now, let’s dig into each track so you can find the best way to secure coverage or minimize out-of-pocket costs.
Track 1: Your Insurance Covers Zepbound or Wegovy, but a Prior Authorization (PA) is Required
If your plan covers obesity medication but requires a PA, getting it approved is all about presenting the right clinical evidence.
Step 1: Who Handles Your PA Matters
Most primary care providers (PCPs) don’t deal with obesity PAs often, which can lead to denials due to errors, missing details, or lack of experience with appeals. This is where a telehealth provider like Ro (ro.co/otp) can help.
Ro processes thousands of PAs every month, meaning their system is designed to fight for approvals in a way that many PCPs simply don’t have the time or expertise for. There are other telehealth providers that also specialize in GLP-1 approvals, but Ro is a trusted option here at On The Pen.
Step 2: Know What to Submit in a PA Request
A well-built PA submission should include:
✅ Diagnosis codes (Obesity: E66.9, Severe Obesity: E66.01)
✅ BMI over 30 (or over 27 with comorbidities like hypertension, T2D, sleep apnea)
✅ Weight loss history (previous attempts with diet, exercise, or other meds)
✅ Medical necessity letter (explaining why alternatives won’t work)
✅ Prior weight-related conditions (OSA, PCOS, Hashimoto’s, CVD)
Step 3: What to Do If You’re Denied
Formulary Exclusion Appeals: If your insurance covers anti-obesity medications but not the drug your doctor is prescribing, your doctor can submit an exception request arguing why the plan's offered alternatives (like Saxenda) are not suitable.
Peer-to-Peer Review: If denied, request a peer-to-peer review, where your doctor speaks directly to the insurance medical director.
Cite Clinical Research: Use studies supporting GLP-1 benefits for conditions like PCOS, CVD, OSA, Hashimoto’s to argue for coverage (see references below).
If all else fails, consider switching providers to one that specializes in PA approvals (Ro or others).
Track 2: Your Insurance Doesn’t Cover Obesity Treatment—Now What?
Even if your plan excludes weight loss medication, you may still get covered under another condition. Recent FDA approvals provide new opportunities:
Option 1: Get Coverage Under Cardiovascular Disease (CVD)
Wegovy (semaglutide) is now FDA-approved for reducing major cardiovascular events.
If you have a history of heart attack, stroke, or high cardiovascular risk, your doctor can submit a PA under this indication instead of obesity.
Option 2: Get Coverage Under Obstructive Sleep Apnea (OSA)
Zepbound (tirzepatide) is now FDA-approved for OSA.
If you have moderate-to-severe OSA (often confirmed with a sleep study), you may qualify for coverage under this diagnosis.
Option 3: Get Coverage for Other Conditions
PCOS (Polycystic Ovary Syndrome) – GLP-1s can help regulate insulin resistance in PCOS.
Hashimoto’s Thyroiditis – Studies suggest GLP-1s improve weight loss outcomes for patients with hypothyroidism.
Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD, formerly NAFLD). Some plans cover GLP-1s for this insulin-resistant liver condition.
How to Fight for Coverage Under These Conditions
Ask your doctor to submit the PA using a different diagnosis.
Provide supporting research studies (see links below).
Use employer advocacy, if you get your insurance through work, HR can sometimes override exclusions.
Track 3: You’re on Medicare or Medicaid
Medicare Coverage
Medicare Part D does NOT currently cover obesity drugs, but that may change in 2025.
If you have Type 2 Diabetes, some GLP-1s like Ozempic and Mounjaro may be covered.
Advocate for future coverage as some states are beginning to cover GLP-1s under Medicaid waivers.
Medicaid Coverage
Coverage varies by state. Some states do cover obesity meds, but many don’t.
If your state denies coverage, an appeal based on secondary conditions (OSA, CVD) may work.
💡 Medicaid Pro Tip: Some states offer "special authorization" pathways that aren’t widely advertised, so ask your provider to check your state’s Medicaid formulary.
Track 4: You Have No Insurance, Cash-Pay Options
If you’re paying out of pocket, your best option may be direct access to Zepbound vials through Lilly Direct.
Option 1: Buy Zepbound Vials from Lilly Direct
Eli Lilly now sells Zepbound in vial form directly for cash-pay patients, offered directly through the Ro platform.
This option is currently only available for the 2.5mg and 5mg doses, but the cash pay prices for a one month supply are $399 and $549 respectively.
Check Lilly Direct for current pricing and availability.
Option 2: Compounded GLP-1s
Some legitimate 503a and 503b compounding pharmacies offer tirzepatide or semaglutide at $250–$400/month due to ongoing nationwide shortages, or to offer non-commercially available doses or formulations.
Be cautious: quality and absorption can vary widely as compounded options are not approved by the FDA. The FDA is cracking down on compounders.
Final Thoughts: Don’t Take ‘No’ for an Answer
If your insurance denies coverage, you still have options:
1️⃣ Fight the PA process with a provider who knows how to win (Ro and others).
2️⃣ Find an alternative coverage pathway (CVD, OSA, PCOS, Hashimoto’s, NAFLD).
3️⃣ Explore cash-pay options (Lilly Direct vials, savings programs, or compounding).
The biggest mistake people make? Giving up after the first denial. Insurance companies count on you quitting. Go armed with the right strategy and documentation, as many patients win appeals and get covered.
If you’ve fought for coverage and won, share your story in the On The Pen community below, your experience could help others get the medication they need.
🔗 Helpful Links for Appeals:
1. Cardiovascular Disease (CVD)
2. Non-Alcoholic Fatty Liver Disease (NAFLD)
https://clinicaltrials.gov/study/NCT04166773?term=SYNERGY&https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-reduce-risk-serious-heart-problems-specifically-adults-obesity-or#:~:text=Today%2C%20the%20U.S.%20Food%20and,including%20heart%20attack%20and%20strokeintr=tirzepatide%20&rank=1&tab=results
3. Polycystic Ovary Syndrome (PCOS)
4. Obstructive Sleep Apnea (OSA)
5. Hashimoto's Thyroiditis
6. Alcohol Use Disorder