Read our comprehensive guide to getting insurance coverage and winning insurance appeals. 

We created this episode because getting insurance coverage and winning denial appeals can be overwhelming, frustrating, and confusing.  Wegovy and Zepbound can costs thousands of dollars a year if you don't get coverage so the stakes are high in getting this coverage many patients. 

Key Takeaways:

• Wegovy and Zepbound offer significant clinical benefits, including substantial weight loss and, for specific patient populations, reduction in cardiovascular risk (Wegovy) or improvement in obstructive sleep apnea (Zepbound). These additional FDA-approved indications can be pivotal for securing coverage, especially under plans like Medicare that restrict coverage for drugs solely for weight loss.
  
  
• The insurance approval process, particularly prior authorization, is a standard hurdle. Being thoroughly prepared with detailed medical documentation, a comprehensive history of previous weight loss attempts (including diet, exercise, and prior medications), and strong support from a healthcare provider are crucial for a successful PA submission.
  
  
• Insurance denials are common but not necessarily the final answer. Patients have the right to appeal these decisions, first through internal appeals with the insurer and then, if necessary, through an independent external medical review. Persistence, coupled with a well-documented case addressing the specific reasons for denial, can often lead to an overturned decision. Appeal success rates are significant enough to make the effort worthwhile.
  
  
• Manufacturer savings programs can substantially reduce out-of-pocket costs for commercially insured patients, both those with and without direct coverage for the medications. However, these programs have limitations, often exclude government beneficiaries, and may not make the drugs affordable for everyone.
  
  
• If coverage for Wegovy or Zepbound cannot be obtained, alternative FDA-approved weight management medications, comprehensive lifestyle interventions (diet, exercise, behavioral support), and, for appropriate candidates, bariatric surgery remain important and effective options to discuss with a healthcare provider. The field of obesity treatment continues to evolve, with new therapies in clinical trials offering future hope.