If you’ve been prescribed Zepbound for obstructive sleep apnea (OSA), you’re probably asking two questions: 1. Will my insurance cover it? and 2. What do I do if coverage is denied? 

You’re not alone – many insurers are dropping or restricting coverage for GLP-1s, so insurance denying Zepbound for sleep apnea is a common problem. The good news is that denials in this case are worth appealing – and many people can get coverage back.

Zepbound (tirzepatide) is FDA-approved to treat moderate-to-severe OSA in adults with obesity, used along with a reduced-calorie diet and increased physical activity. In fact, it’s the only GLP-1 that’s approved to treat OSA. That means that even if your plan limits coverage of GLP-1s for weight loss, you can still get Zepbound covered for sleep apnea.

Quick answers: Zepbound + sleep apnea insurance

Q: Does insurance cover Zepbound for sleep apnea?

A: Some insurance plans cover Zepbound for sleep apnea, but coverage usually requires prior authorization. Your provider may need to submit documentation including your sleep study results, diagnosis, and proof that you meet obesity or BMI criteria. If insurance denies your request, don’t stop there. Many people are able to win coverage by submitting an appeal. 

Q: What do I do if insurance denies Zepbound for sleep apnea?

A: If insurance denies Zepbound for sleep apnea, start by getting the denial letter and noting the exact reason for the denial (you may see language like “not medically necessary” or “not on formulary”). Then submit an appeal that includes your sleep study results, records of your diagnosis, obesity/BMI details, and (optional but recommended) a letter of medical necessity from your doctor. If needed, request a second review of your appeal or escalate to independent review. 

If you get denied, save this quick overview of the process.

1. Save the denial letter.
2. Identify the reason you were denied.
3. Gather documentation to support your case.
4. Submit the right next move based on your denial reason. 
5. Escalate to a second or external review if needed.

Not sure why you were denied or which next step is right for you? Use Claimable’s easy tool to guide you step-by-step through the appeals process.

Insurance denied Zepbound for sleep apnea? Here’s what to do (Step by Step)

Step 1 — Read the denial reason and appeal instructions

Before you jump into action, find these things in your denial letter or portal message. 

• The reason you were denied. Look in your letter for language like “Why your request was denied”.
• Appeal instructions. Your denial letter will provide information about how to appeal and where to send your request (fax or mail). 
  
  • Note: You might get a message in your portal before the formal denial letter comes in the mail. You don’t have to wait for the denial letter to come in order to appeal – log into your insurer’s member website and search for appeal department details. 

Step 2 — Identify why you were denied

Most denials fall into one of these buckets. Look for language like one of these in your denial letter under “why your request was denied”. 

When it comes to Zepbound for sleep apnea, all of these denial reasons can be challenged and you can get coverage back. It’s just about identifying the right steps to take.

• Prior authorization incomplete: The PA your doctor submitted may have missing fields or missing attachments.
• Not medically necessary: Your plan says you don’t meet their criteria to be covered for Zepbound.  
• Not on formulary: This isn’t a medication included in your plan’s list of covered drugs. They’ll want you to try an alternative.
• Not a covered benefit: Your plan excludes weight loss medications and isn’t recognizing sleep apnea as the primary diagnosis for Zepbound. 
• Step therapy / alternative required: They want you to try something different before they’ll approve coverage for Zepbound.

Step 3 — Choose the right next action

• If it’s missing info → ask your doctor to correct and resubmit the PA.
• If it’s criteria/medical necessity → Make sure you meet the criteria, then file an appeal. Getting a letter of medical necessity from your doctor can help here. If your insurer is requiring unreasonable criteria that doesn’t match the current FDA or clinical guidelines, Claimable can help you make that case.
• If it’s formulary → Appeal and request a formulary exception. Since Zepbound is the only GLP-1 that’s approved for sleep apnea, you should qualify for a formulary exception.
• If it’s an exclusion → Ask your doctor to file a new PA only for OSA (not obesity). If you’re denied again, appeal. Exclusions are common for obesity, but not for sleep apnea. This happens when your request is mis-categorized, so you can clear things up in an appeal.

Zepbound for sleep apnea: Coverage overview

Does insurance cover Zepbound for sleep apnea? Sometimes, yes—but it’s usually not automatic.

“Coverage” typically depends on:

• whether the medication is on your plan’s formulary
• whether you meet prior authorization criteria
• whether required documentation is submitted correctly the first time

Zepbound’s OSA indication is specifically for moderate-to-severe obstructive sleep apnea in adults with obesity (with diet and activity), so you want to make sure it’s right for you.

What insurers usually require to cover Zepbound for sleep apnea

This varies by plan, but the most common things insurance wants to see to cover Zepbound for sleep apnea are below. Call your insurer or visit your member website for a full list of coverage criteria. You can see example coverage criteria from CVS Caremark here.

Sleep study + documented OSA severity

• Sleep study report (polysomnography or home sleep apnea test, as applicable)
• Documented diagnosis of OSA and severity (often based on AHI/REI)

Obesity/BMI documentation + relevant clinical history

• Current height/weight, BMI
• Problem list / relevant comorbidities (as documented in chart notes)

Provider notes that align to plan criteria

• Recent visit notes with diagnosis and treatment plan
• Any documentation the plan requires (e.g., specialist involvement, prior treatment history)

Tip: A surprising number of denials happen because the right info exists—but it isn’t included in the PA submission or isn’t easy for the reviewer to find.

Common denial reasons and what to do about them

Denials are confusing. Here’s a breakdown of the most common denial reasons, what they look like in communications from your insurance, and how to fix it. Need help determining which reason you have and what strategy to use? Use Claimable's guided appeals tool to make it easy.

1) Prior auth incomplete / missing documentation

What it looks like: “Insufficient information,” “missing documentation,” “clinical records not provided.”
Fastest fix: Ask your prescriber’s office what they submitted, then resubmit with a complete packet.

2) “Not medically necessary”

What it looks like: “Does not meet criteria,” “not medically necessary.”
Fastest fix: Appeal using your plan’s stated reason. Clearly show that you meet the missing criteria – or that the criteria your insurer uses isn’t backed up by FDA or clinical guidelines (Claimable can help with this).

3) Not on formulary

What it looks like: “Not covered,” “non-formulary,” “preferred alternatives required.”
Fastest fix: Appeal, requesting a formulary exception. Include details about why alternatives aren’t suitable for you based on your condition or medications you’ve tried and failed in the past.

4) Benefit exclusion / “weight loss only”

What it looks like: “Plan excludes weight-loss medications,” “not a covered benefit”
Fastest fix: This is where the OSA indication matters. Zepbound is FDA-approved for moderate-to-severe OSA in adults with obesity – so an exclusion for weight-loss medication shouldn’t apply here. Appeal to make the case.

5) Step therapy / alternative requirement

What it looks like: “Must try X first,” “step edit.”
Fastest fix: Include information about why alternatives aren’t appropriate in your appeal. Lean on relevant state laws here – 37 states have laws that protect patients from step therapy requirements, so you may not be required to try and fail an alternative first.

How to get insurance to cover Zepbound for sleep apnea – before you have to deal with a denial

If your doctor is considering prescribing you Zepbound for sleep apnea, get ahead of any issues by determining if you’ll covered from the start.

What to ask your insurer (script)

Call the number on your insurance card and ask:

1. Is Zepbound covered for obstructive sleep apnea under my plan?
2. Is it on formulary? If not, what’s the exception process?
3. What are the prior authorization criteria and where is the PA form?
4. Where should the PA be submitted (portal/fax)?
5. What are typical timelines, and what qualifies for an expedited review?

What to ask your provider (submission checklist)

Ask your clinician’s office to confirm the PA includes:

• Sleep study report + OSA severity documentation
• BMI/obesity documentation
• A brief medical rationale tied to criteria (not generic)
• the correct diagnosis coding and chart notes attached

Common submission mistakes to avoid

• Missing the sleep study attachment
• Outdated weight/BMI documentation
• Generic notes that don’t address the plan’s stated criteria
• Incorrect submission destination (wrong portal/fax)

How to write a Zepbound for sleep apnea appeal

Insurance is complicated, and even when you get ahead of it issues can arise. But when it comes to Zepbound for sleep apnea, most people will be able to reverse a denial when they appeal – with the right argument, documentation, and clinical backing.

What to include in your appeal

Your appeal is strongest when it mirrors the denial reason:

1. Quote the denial reason (one sentence)
2. Respond directly with the evidence that addresses it
3. Attach the supporting documents and highlight the relevant lines. Include:
   
   1. Sleep study report
   2. OSA diagnosis
   3. Clinic notes and/or letter of medical necessity
   4. Clinical studies that support why Zepbound is right for you
   5. Any relevant laws – many states have legal protections that can help fight formulary changes, step therapy, and other inappropriate denial reasons.

If it’s a formulary appeal

1. Make sure you’re clearly stating that this is a formulary exception request
2. Look up what the plan is offering for alternatives, and make sure that you’re clearly laying out why those are inappropriate for you

Request a second review (internal escalation)

If your first appeal is denied:

• Request a second-level internal appeal from your plan. Do this by sending another appeal and noting your request on the first page – making sure you address the reason for their denial. If your insurance has a separate mail/fax for second-level appeals, send it there.

External/independent review (when internal appeals fail)

By law, most plans are required to offer access to external review (independent review) after a final internal denial. Your denial paperwork should tell you how to request it. 

If your plan still won’t cover it

If you’ve exhausted the plan’s pathways, you can still explore:

• Employer benefits escalation (HR/benefits team can sometimes clarify exceptions)
• Manufacturer resources and savings programs (where eligible)
• Legal action. There are several class-action lawsuits underway regarding inappropriate denial of Zepbound coverage for OSA patients, or you can speak with a lawyer about your individual options.

Read our full guide here to what to do when your appeal is denied.

Always avoid delaying OSA management—talk with your clinician about other treatment options while coverage is being sorted.

How Claimable helps

We get it – navigating the insurance process isn’t always easy! That’s where Claimable comes in. Use our appeals tool to:

• Identify the most likely reason you were denied
• Create an expert-backed appeal letter that includes clinical, policy, and legal evidence to make the case for coverage for your specific situation
• Automatically mail and fax to the right place
• Escalate to the next level if your first appeal is denied

Start your Zepbound sleep apnea appeal with Claimable.

FAQs

What do I do if insurance denies Zepbound for sleep apnea?

tart by getting the denial letter and noting the exact reason for the denial (you may see language like “not medically necessary” or “not on formulary”). Then submit an appeal that includes your sleep study results, records of your diagnosis, obesity/BMI details, and (optional but recommended) a letter of medical necessity from your doctor. If needed, request a second review of your appeal or escalate to independent review. 

How do I appeal for Zepbound for sleep apnea?

Write a clear letter that outlines your case for coverage: Restate the denial reason, respond with the exact evidence that addresses it, and attach the documents (sleep study, chart notes, BMI). Ask your provider for a letter of medical necessity if helpful. Mail and fax to your insurer’s appeals department.

Why did insurance deny Zepbound for sleep apnea?

Common reasons include missing PA documentation, “not medically necessary,” the drug being non-formulary, benefit exclusions, or step therapy requirements. These can all be challenged with an appeal.

What does “not medically necessary” mean in a Zepbound sleep apnea denial?

It usually means the plan believes the documentation doesn’t prove you meet its criteria. Your appeal should focus on supplying the specific missing evidence and clarifying anything the reviewer may have missed.

What should I submit if my Zepbound sleep apnea prior authorization was denied?

Resubmit the PA, or appeal with a complete packet: denial letter, PA materials, sleep study, diagnosis/severity documentation, BMI/obesity documentation, and relevant clinician notes.

Can I appeal a plan exclusion denial for Zepbound for sleep apnea?

Often, yes – plans may still have an exception process. Most plan exclusions are when GLP-1s are for weight loss – a prescription for sleep apnea shouldn’t fall under that exclusion. However, it’s common for Zepbound to be initially denied because of exclusions, and patients may need to appeal to get coverage for OSA. Even when exclusions exist, your denial letter should explain appeal rights and next steps. 

What is a formulary exception and when should I request one?

A formulary exception is a request for coverage when a medication isn’t on your plan’s formulary (the list of covered drugs). It’s most relevant when your denial says “not covered” or “non-formulary.”

How do I request an independent review after my appeal is denied?

After a final internal denial, you may be eligible for external review through an independent organization; your plan’s final denial should include instructions on how to request external review. Claimable recommends always exhausting your appeals through the final pathway before giving up. 

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For many people living with obesity, the biggest insurance challenge isn’t a denial for a specific drug — it’s that the plan doesn’t cover any medication for that condition at all, even if the drug is FDA approved for that condition and covered for other conditions. “Plan exclusions” are becoming more common as the popularity of GLP-1 medications increases. If you’re facing one, you’re probably thinking: What do I do now?

How do I know if I have a plan exclusion for GLP-1s?‍

If your GLP-1 was denied, look for language like this in the denial letter. This type of language typically indicates a plan exclusion.

• “Not a covered benefit”
• “Your benefit plan simply does not cover this medication, no matter what the reason is that it is being requested”
• “We denied this request based on general exclusion section of formulary”
• “Your plan does not cover this drug when it is used for weight loss”
• “For this drug, you may have to meet other criteria”
• “This request has been administratively denied"
• “Excluded from coverage”
• “Not eligible"

You may have also received a letter in the mail ahead of your 2026 plan year notifying you of coverage changes like plan exclusions. Check your letter or plan documents for language like “medications prescribed for weight loss are excluded” or "not covered".

Plan Exclusion vs. Formulary Exclusion: What’s the Difference?

Plan exclusions and formulary exclusions are two of the most common reasons insurance denies covered. Formulary exclusions, however, are easier to fight. It’s important to understand which one you’re dealing with.

Formulary Exclusion (A Specific Drug Isn’t Covered)

A formulary is the list of drugs your insurance plan agrees to cover. Plans frequently:

• exclude certain drugs, asking patients to use their preferred alternatives instead
• place them in high cost-sharing tiers, or
• cover them only for one use (e.g., diabetes) but not another (e.g., obesity). 

If the plan covers the condition (e.g., diabetes) but simply doesn’t cover your particular drug, you can ask for a formulary exception. 

Formulary exceptions have a legally protected process for all insurance plans, requiring them to reconsider whether a medication should be covered— even if it’s not on the formulary—because the alternatives are not equivalent and acceptable for you. Learn more about formulary exceptions and how to get one here.

Plan Exclusion (No Drugs For Your Condition Are Covered))

A plan exclusion means the plan’s policy explicitly states that it won’t cover any medicines for a specific condition category. For weight-loss medications, this often shows up as a “Weight Loss Plan Exclusion.” 

This is much harder to challenge. Unlike targeting coverage for one drug, you have to argue that the plan shouldn’t categorically avoid covering any medication for your condition. Plans are legally allowed to exclude coverage for obesity treatment because obesity is currently not recognized by Health & Human Services as a disease. Which means they can write the plan to omit all pharmacologic treatment for obesity. 

Why Obesity — But Not Other Conditions — Can Be Excluded

Under the Affordable Care Act (ACA), health plans must offer a set of Essential Health Benefits (EHBs) like hospitalization, prescription drugs, mental health care, etc. Think of these as “the basics” that you’d need to have reasonable care with an insurance plan. But obesity treatment itself is not currently listed as an EHB that plans must cover. 

That’s why insurers can choose a plan that says “no coverage for medications prescribed for weight loss,” and courts have generally declined to force coverage. 

By contrast, plans cannot exclude essential services for conditions like:

• Obstructive Sleep Apnea (OSA): A sleep disorder where obesity is a primary risk factor. Treatment for OSA is typically covered even when obesity medications are not.
• Metabolic Dysfunction–Associated Steatohepatitis (MASH): A fatty liver disease linked to obesity and commonly covered by insurance, despite the exclusion of obesity treatment.
• Major Adverse Cardiovascular Events (MACE), including Stroke (CVA): Serious heart attack and stroke outcomes. Treatment and prevention are broadly covered even though obesity is a major underlying risk factor.

This highlights a major problem with insurance coverage: health plans will pay to treat illnesses caused by obesity once they’ve become severe enough, but they won't pay for the obesity treatment itself. Treating obesity could actually lower the risk of all those other diseases – but insurance doesn’t want to cover it until bigger issues arise.

Why Plan Exclusions Are Difficult to Appeal

When a claim is denied based on a plan exclusion, insurers usually respond:

“This service is not a covered benefit under your plan.”

That’s not a denial that the treatment is  medically  necessary for you  — it’s a statement that the plan has no obligation whatsoever to pay for it even if it is. Because of this, most appeals get rejected without any deeper review of your clinical circumstances.

So if your plan’s written documents (e.g., Summary Plan Description or Evidence of Coverage) explicitly state that “medications prescribed for weight loss are excluded,” there’s often no administrative appeal pathway under the plan itself — because, under the plan’s terms, you aren’t eligible for that benefit at all. 

What You Can Do If Your Plan Doesn’t Cover Medications For Weight Loss

Here are practical options when you’re up against a plan exclusion:

1) Appeal to Your Employer Directly

If you’re on a self-funded employer plan, you can ask them to make an exception. Self-funded employer plans are a common type of healthcare plan that is designed and funded by the employer itself Most people with healthcare through their employer have this type of plan. A self-funded plan  means your employer:

• Can grant exceptions to plan rules;
• Has a fiduciary duty to act in the best interests of participants;
• May be exposed to risk if an exclusion appears arbitrary or discriminatory.

Some employers are willing to make case-specific exceptions if presented with compelling medical evidence and employee support. This usually involves writing to HR or your benefits administrator, explaining:

• why the exclusion harms health outcomes,
• how coverage would improve health and reduce long-term costs,
• that the exclusion may conflict with anti-discrimination principles or ERISA fiduciary standards

Get our FREE sample letter to employer benefits admin at the bottom of this post 👇

How to make your appeal to HR even more effective? Organize with other colleagues impacted by the plan exclusion to show the full scale of the issue.

2) Advocate for Policy Change

If your health plan excludes obesity treatment, it’s not because the science is lacking — it’s because U.S. health policy hasn’t caught up. Changing that requires action beyond individual appeals.

Here are a few meaningful ways to get involved.

• Support federal legislation. The Treat and Reduce Obesity Act (TROA) is an active bill in Congress that would expand Medicare coverage for FDA-approved obesity treatments and help establish obesity as a condition deserving comprehensive medical care. Medicare policy often influences private insurers, making this a critical step toward broader coverage.
• Protect and expand coverage in public programs. Coverage for obesity medications is actively being debated in Medicare, Medicaid, TRICARE, and state employee health plans. Advocacy efforts are underway to prevent coverage rollbacks and support state-level bills that expand access to care.
• Engage in policy advocacy and education. Public comments, patient stories, and education efforts play a real role in shaping insurance and regulatory decisions. Elevating lived experiences helps counter outdated assumptions that continue to drive exclusions.

One of the easiest ways to participate is through the Obesity Action Coalition (OAC), a leading nonprofit organization advocating for people living with obesity. OAC provides tools to:

• Sign petitions
• Contact elected representatives
• Support active federal and state legislation
• Share experiences that inform policy advocacy
  

👉 Learn more and take action at obesityaction.org/action-center

Policy change takes time, but it’s the only path to permanently ending blanket exclusions for obesity treatment. Individual voices matter — especially when they’re raised together.

3) Explore Cash Pay and Direct Pay Options

Even when insurance coverage is excluded, there are increasingly affordable cash-pay options for weight-loss medications:

• Wegovy: Newly released oral Wegovy tablets are available for approximately $149–$299 per month, depending on dose. Cash-pay injectable Wegovy options are available starting around $349 per month. Visit NovoCare for current pricing and eligibility details.
  
  
• Zepbound: Cash-pay Zepbound vials are available for approximately $299–$449 per month, depending on dose. At this time, prefilled Zepbound injection pens are not offered at a reduced cash-pay price. Visit LillyDirect for current pricing and eligibility details.

These direct-to-consumer programs are not insurance coverage, but they can provide access when a health plan excludes treatment. A valid prescription from a licensed healthcare provider is required.

FAQs

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Why is my GLP-1 not covered by insurance?

There are a few common reasons: your plan may have a weight loss medication exclusion, the specific drug may not be on the formulary, or your request may require prior authorization and didn’t meet the plan’s criteria. The denial letter usually includes the exact reason—look for phrases like “not a covered benefit,” “excluded from coverage,” or “not on formulary.”

What does it mean when a GLP-1 is “not a covered benefit”?

“Not a covered benefit” usually means your plan explicitly excludes treatments for your condition. This is increasingly common for GLP-1s. In many cases, your next step is to request the plan’s written policy language as well as explore if other conditions you have been diagnosed with, like sleep apnea or fatty liver disease, are eligible for coverage for the medication.

What does “excluded from coverage” mean on a denial letter?

“Excluded from coverage” typically means your plan documents explicitly state the plan does not cover the drug (or drug category) for that use (often weight loss). It’s still worth confirming whether it’s a true plan exclusion versus a drug-specific formulary issue or an administrative error.

Is a plan exclusion the same as a formulary exclusion?

No. A formulary exclusion means the plan doesn’t cover a specific drug (or prefers alternatives). A plan exclusion means the plan doesn’t cover any drugs for a category/condition (like weight loss medications), which is typically harder to overturn.

Can I appeal a plan exclusion for Wegovy, Zepbound, or other medications?

Sometimes – but it depends on the plan and the type of decision being made. If your denial is truly based on a plan exclusion, a standard appeal may be limited; however, you may still be able to request a coverage exception, pursue an employer-level exception (for employer-sponsored plans), or escalate through available review options if the plan allows it.

Why does my plan cover Zepbound for OSA or Wegovy for MASH, but not for weight loss?

Many plans cover GLP-1s for specific diagnoses (like diabetes or OSA) but exclude or restrict coverage for weight loss/obesity. Your denial letter may say the plan “only covers this drug for certain conditions” or that it’s “not covered for your diagnosis.”

Does insurance cover Wegovy for weight loss?

Some plans do, but many require prior authorization and some plans exclude weight loss medications entirely. The fastest way to confirm is to check your plan formulary and your plan’s pharmacy benefit rules—and if you’re denied, review the denial letter for whether it’s a criteria denial or a plan exclusion.

Does insurance cover Zepbound for weight loss?

Some insurance plans cover Zepbound for weight loss with prior authorization, while others exclude weight loss medications as a benefit category. If you’re denied, the exact wording matters: “criteria not met” usually means you can appeal with documentation, while “excluded from coverage” may require an exception or employer benefits route.

Are weight loss drugs covered by insurance in general? Which insurance plans cover weight loss?

Sometimes, but it’s inconsistent. Many plans cover certain weight loss treatments or programs, while excluding weight loss medications – or covering them only under strict criteria and prior authorization rules. The most reliable way to know is to check your specific plan’s language.

Which weight loss medications are most likely to be covered?

Coverage depends on the plan’s formulary, tiering, and prior authorization rules. Some plans cover a limited set of medications or prefer certain options, while excluding others. If your plan covers weight loss medications at all, the next step is often figuring out which drugs are preferred and what documentation is required.

What should I do if my GLP-1 is denied as “not medically necessary”?

That’s usually not a plan exclusion—it typically means the plan thinks the request doesn’t meet coverage criteria or doesn’t have enough documentation. Ask for the exact criteria used, gather supporting documentation with your prescriber, and submit an internal appeal or resubmission (depending on plan instructions).

If my plan excludes weight loss medications, can my employer override it?

Sometimes—particularly for employer-sponsored plans, where benefit design decisions may be made by the employer. Employees can sometimes request the employer/benefits administrator review the exclusion or consider an exception process. (This varies by employer and plan structure.)

How do I find out if my plan is self-funded?

You can ask your HR/benefits team or the plan administrator. You can also look in your plan documents for language about who pays claims (employer vs insurer) or who the plan sponsor is. If you’re unsure, ask: “Is this plan self-funded or fully insured?”

Can I switch insurance plans to get GLP-1 coverage?

If you have an opportunity to change plans (like open enrollment or a qualifying life event), you can compare formularies and benefit exclusions before enrolling. Make sure you’re checking both (1) whether the drug is covered and (2) whether weight loss medications are excluded.

If insurance won’t cover my GLP-1, what are my options?

Options may include pursuing an exception pathway (if available), employer benefits advocacy (for employer coverage), exploring manufacturer savings programs (if eligible), or cash-pay/direct-pay programs. Which option is best depends on whether your denial is a true plan exclusion or a criteria/formulary denial.

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Free Sample Letter to Employer / Benefits Admin:
Coverage Exception & Policy Review Request (Self-Funded Employer Plan)

[Your Name]
[Street Address]
[City, State, ZIP]
[Phone Number]
[Email Address]
[Date]

[Benefits Committee or HR Representative Name]
[Job Title]
[Company Name]
[Company Address]

Dear [Benefits or Human Resources Representative Name],

I am writing to ask for your help with health insurance coverage for medical care that my healthcare provider has determined is medically necessary. I am grateful for the benefits that [Company Name] provides and for the company’s stated commitment to employee well‑being, equity, and long‑term health. It is in that spirit that I am requesting a case‑specific exception to our current health plan’s exclusion of obesity treatment.

I live with the chronic disease of obesity and have been prescribed [name of medication or treatment] by my clinician as part of a comprehensive treatment plan. This recommendation follows sustained lifestyle interventions and reflects current medical consensus regarding evidence‑based obesity care. I recently learned that our plan, [plan name / administrator], excludes coverage for medications prescribed for obesity, regardless of medical necessity.

This exclusion has made clinically appropriate care inaccessible and financially prohibitive for me. Obesity has already had meaningful impacts on my health and quality of life, including [briefly describe related conditions, risks, or symptoms]. My provider has determined that continued treatment is critical to improving my health trajectory and reducing future medical risk.

Why I Am Requesting an Exception:
Obesity Is a Chronic Disease With Serious Health Consequences

Obesity is widely recognized by the medical community as a chronic, progressive disease associated with increased risk of cardiovascular disease, type 2 diabetes, stroke, certain cancers, sleep apnea, and other serious conditions. National data show that more than 40% of U.S. adults live with obesity, and obesity‑related medical costs exceed $170 billion annually. Treating obesity improves health outcomes and reduces long‑term healthcare costs for both individuals and employers.

Importantly, not all obesity treatments work for all patients. Clinical guidelines emphasize the need for individualized care, including FDA‑approved pharmacologic therapies when lifestyle interventions alone are insufficient. Denying access to these therapies limits clinicians’ ability to provide patient‑centered care and places employees at increased risk of preventable disease progression.

Considerations for Self‑Funded Plans

I understand that [Company Name] sponsors a self‑funded health plan. As the plan sponsor, the company retains discretionary authority over benefit design and coverage decisions and holds fiduciary responsibility under the Employee Retirement Income Security Act (ERISA) to act prudently and in the best interests of plan participants.

While insurers or third‑party administrators may apply plan exclusions as written, the employer has the authority to grant individual coverage exceptions, and review whether existing exclusions continue to align with fiduciary obligations, medical standards, and employee well‑being.

I am therefore requesting review at the employer level, rather than through the insurer’s standard appeal process, which does not evaluate medical necessity when a categorical exclusion applies.

Policy and Clinical Standards (For Consideration)

While I am not a lawyer, I believe it is important for the plan sponsor to be aware of the evolving policy and clinical standards related to obesity care, which increasingly recognize obesity as a chronic disease requiring evidence-based treatment.

1. Federal Policy Momentum Reflecting Changing Standards of Care

Obesity treatment access is an active area of federal policy consideration. The Treat and Reduce Obesity Act (TROA) has been reintroduced in Congress and would expand Medicare coverage for obesity treatment, including FDA-approved medications and access to specialized providers. While TROA has not yet been enacted, its bipartisan reintroduction reflects a growing recognition at the federal level that obesity warrants comprehensive medical treatment.

Importantly, Medicare policy often serves as a bellwether for commercial insurance coverage and employer-sponsored plan design. These developments signal that longstanding exclusions for obesity treatment may be increasingly misaligned with emerging coverage norms.

2. Inconsistent Coverage of the Same Medications Across Diagnoses

Many health plans, including ours, cover GLP-1 medications when prescribed for type 2 diabetes but exclude coverage when the same medications are prescribed for obesity. This distinction exists despite substantial clinical evidence supporting their use for both conditions and growing consensus that obesity is a chronic, progressive disease.

As clinical guidance evolves, coverage decisions based solely on diagnosis—rather than individualized medical need—are increasingly being questioned by clinicians, policymakers, and plan sponsors alike. Several recent legal and policy discussions have focused on whether such distinctions reflect medical evidence or historical coverage conventions.

3. Current Clinical Guidance Supporting Obesity Treatment

Leading medical organizations continue to update standards of care to reflect advances in obesity treatment. For example, the American Diabetes Association’s Standards of Care emphasize the importance of addressing obesity as part of preventing and managing metabolic disease, including the appropriate use of pharmacologic therapy when lifestyle interventions alone are insufficient.

These guidelines reflect broader clinical consensus that obesity treatment should be individualized, evidence-based, and integrated into chronic disease management—not categorically excluded.

4. Fiduciary Considerations for Self-Funded Plan Sponsors

For self-funded employer-sponsored health plans governed by ERISA, plan sponsors have fiduciary responsibility to administer benefits prudently and in the best interests of plan participants. This includes periodically reassessing plan design choices in light of evolving medical standards, treatment effectiveness, and participant impact.

In this context, targeted, case-specific exceptions for evidence-based obesity treatment can be a measured approach that supports employee health while allowing plan sponsors to thoughtfully evaluate whether existing exclusions remain appropriate as standards continue to evolve.

My Request

In light of the above, I respectfully request that [Company Name]:

1. Grant a case‑specific coverage exception for my prescribed obesity treatment based on medical necessity; and
2. Consider reviewing the plan’s obesity treatment exclusion to ensure it aligns with current medical standards, fiduciary responsibilities, and the company’s commitment to employee health and equity.

I am happy to provide supporting documentation from my healthcare provider, including clinical rationale and treatment history, if helpful. I would welcome the opportunity to discuss this request or understand the next steps for review.

Thank you for your time, consideration, and commitment to supporting the health of your employees.

Sincerely,[Your Name]

In August 2025, the FDA approved Wegovy to treat MASH: metabolic dysfunction–associated steatohepatitis, commonly known as fatty liver disease. This was great news for many with the disease, offering new hope to improve liver inflammation and fibrosis.

So while there’s a reason to be optimistic if you’ve been prescribed Wegovy for fatty liver, you probably also have questions. Two of the most common ones are 1. Will my insurance cover it? and 2. What do I do if coverage is denied?

You’re not alone. Denials are common right now because many insurers still apply broad GLP-1 rules, or haven’t fully updated workflows for this newer liver indication. The good news: many of these denials are worth appealing, and patients often get to “yes” with a strong request and the right information.

Wegovy (semaglutide 2.4 mg) is FDA-approved to treat noncirrhotic MASH with moderate-to-advanced fibrosis (F2–F3) in adults, used alongside diet and physical activity. It’s the first and only GLP-1 therapy approved specifically for MASH.

Quick answers: Wegovy + fatty liver (MASH) insurance

Q: Does insurance cover Wegovy for fatty liver (MASH)?

A: Some insurance plans cover Wegovy for fatty liver disease when it’s prescribed for MASH, but coverage usually requires prior authorization. Your provider may need to submit documentation showing your MASH diagnosis and fibrosis stage (often F2–F3), along with supporting test results and clinical notes. If insurance denies your request, don’t stop there. Many people are able to win coverage by submitting an appeal – especially when the denial is based on a blanket GLP-1 policy or criteria that hasn’t caught up yet. 

Q: What do I do if insurance denies Wegovy for fatty liver (MASH)?

A: If insurance denies Wegovy for fatty liver (MASH), start by getting the denial letter and noting the exact reason for denial (you may see language like “not medically necessary” or “not on formulary”). Then submit an appeal that includes documentation of your MASH diagnosis, your fibrosis staging, supporting test results, and (optional but recommended) a letter of medical necessity from your doctor explaining why Wegovy is being prescribed for MASH. If needed, request a second review or escalate to external/independent review. 

If you get denied, save this quick overview of the process.

1. Save the denial letter.
2. Identify the reason you were denied.
3. Gather documentation to support your case.
4. Submit the right next move based on your denial reason. 
5. Escalate to a second or external review if needed.

• Escalate to second-level and then external review if needed. 

Not sure why you were denied or what the best next step is? Claimable can guide you through the appeals process step-by-step. Get started here.

Insurance denied Wegovy for fatty liver? Here’s what to do (Step by Step)

Step 1 — Read the denial reason and appeal instructions

Before you do anything else, locate:

• The reason you were denied (often under “Why your request was denied”)
• Appeal instructions (where to send it and how—fax, mail, or portal upload)

Tip: You might see a portal message before the formal letter arrives. You usually don’t need to wait—log in to your insurer’s member site and look for appeals instructions. 

Step 2 — Identify why you were denied

Most denials for Wegovy + MASH fall into buckets like these:

• Prior authorization incomplete: missing fields, missing attachments, or missing test results.
• Not medically necessary / does not meet criteria: the plan says the documentation didn’t prove you qualify (often a fibrosis staging issue).
• Not on formulary / non-formulary: the plan doesn’t list Wegovy as covered for this use, or requires an exception path.
• Not a covered benefit / “weight loss drugs excluded”: the plan is treating the request like obesity coverage—even if your prescription is for MASH.
• Alternative required / step edit: the plan wants a different option first, or wants a rationale for why alternatives aren’t appropriate (this varies a lot by plan).

The key: many of these are fixable once you match your response to the specific denial reason.

Step 3 — Choose the right next action

Use this as your decision tree:

• If it’s missing info → ask your provider to correct and resubmit the PA with a complete packet.
• If it’s criteria/medical necessity → confirm you meet criteria and file an appeal. A clinician letter of medical necessity helps here. If your insurer’s criteria isn’t aligned with clinical or FDA guidelines, Claimable can help make the case that you shouldn’t be held to unreasonable requirements. 
• If it’s formulary → appeal and request a formulary exception. Since Wegovy is the only GLP-1 that’s approved for MASH, you should qualify for a formulary exception.
• If it’s an exclusion / “weight loss only” → ask your clinician to ensure the request is clearly for MASH and not miscoded as “weight management.” If denied again, appeal and make the case that the MASH indication is being overlooked.

Wegovy for fatty liver (MASH): Coverage overview

Does insurance cover Wegovy for fatty liver disease? Sometimes, yes—but it’s usually not automatic.

“Coverage” typically depends on:

• Whether Wegovy is on your plan’s “formulary” or list of covered drugs
• Whether you meet prior authorization criteria, and
• Whether the required documentation is submitted correctly the first time.

Also important: “fatty liver” is a broad term. Wegovy’s liver indication is for MASH with moderate-to-advanced fibrosis (F2–F3) in adults without cirrhosis—so if documentation only says “fatty liver” without staging, reviewers may deny because they can’t confirm you meet the labeled criteria. 

What insurers often require to cover Wegovy for MASH (examples)

Requirements vary by plan, but common criteria include:

1) Proof of the right diagnosis + stage

Many plans look for:

• Noncirrhotic MASH
• Fibrosis stage F2 or F3
• Confirmation via biopsy or accepted noninvasive tests (some policies specify a timeframe, like within the last 180 days). 

2) Specialist involvement

Some policies require Wegovy to be prescribed by (or in consultation with) a gastroenterologist/hepatologist. 

3) Safety/eligibility checks

You may see requirements like:

• Adult age threshold (often ≥18) 
• Confirmation you don’t have cirrhosis or other excluded liver disease causes 
• Attestation about certain concurrent medications (plan-specific) 

Tip: a surprising number of denials happen because the information exists—but it isn’t included in the PA packet, or the fibrosis staging isn’t easy for the reviewer to find.

Common denial reasons and what to do about them

Denials are confusing. Here’s a breakdown of the most common denial reasons, what they look like in communications from your insurance, and how to fix it. Need help figuring out why you were denied and which strategy is right? Use Claimable's guided appeals tool to make it easy.

1) Prior auth incomplete / missing documentation

What it looks like: “Insufficient information,” “missing documentation,” “clinical records not provided.”
Fastest fix: Ask what was submitted, then resubmit with a complete packet (see checklist below). (Some plans explicitly require staging documentation.) 

2) “Not medically necessary” / “does not meet criteria”

What it looks like: “Not medically necessary,” “does not meet criteria.”
Fastest fix: Appeal and show, point-by-point, that you meet criteria (especially noncirrhotic MASH + F2–F3), citing the test that confirms staging and attaching the relevant pages. 

3) Not on formulary

What it looks like: “Not covered,” “non-formulary,” “preferred alternatives required.”
Fastest fix: Appeal and request a formulary exception. These typically require your prescriber to submit a supporting statement that the non-formulary medication is medically necessary. 

4) Benefit exclusion / “weight loss medications excluded”

What it looks like: “Plan excludes weight-loss drugs,” “not a covered benefit.”
Fastest fix: This is where diagnosis clarity matters. If the insurer is applying a weight-loss exclusion to a MASH prescription, your appeal should explicitly explain the indication and include staging evidence and your clinician’s rationale. 

5) Alternative required / “step edit”

What it looks like: “Must try X first,” “step therapy.”
Fastest fix: Address alternatives directly. Today, MASH also has other FDA-approved treatment options (for example, resmetirom/Rezdiffra is FDA-approved for noncirrhotic MASH with F2–F3). Some plans may want to understand why an alternative isn’t appropriate for you—or why Wegovy is the right option for your clinical situation. 

How to get insurance to cover Wegovy for fatty liver (MASH) — before you deal with a denial

What to ask your insurer

Call the number on your insurance card and ask:

• Is Wegovy covered for MASH (fatty liver/NASH) under my plan? 
• Is it on formulary? If not, what’s the formulary exception process?
• What are the prior authorization criteria (and can you send them to me)?
• What proof of F2–F3 fibrosis is accepted (biopsy vs elastography/MRE, etc.)?
• Is a hepatologist/gastroenterologist required?
• Where should the PA be submitted (portal/fax), and what are typical timelines?
• What qualifies for expedited review if my clinician believes delay is risky? 

What to ask your provider

Ask your clinician’s office to confirm the PA includes:

• MASH diagnosis (and “fatty liver” context, if that’s how it appears in chart history)
• Fibrosis staging (F2–F3 if applicable) + the test that supports it (attach the report)
• Confirmation of noncirrhotic status (and any relevant exclusions)
• A brief rationale tied to the plan’s criteria (not generic)
• Correct diagnosis coding and the right chart notes attached

Common submission mistakes to avoid

• Using only “fatty liver” language with no mention of MASH and no fibrosis stage
• Missing the fibrosis staging report attachment
• Generic chart notes that don’t address the plan’s criteria
• Mislabeling the request as “weight management” instead of a liver indication

How to write a Wegovy for MASH appeal

The strongest appeals mirror the denial reason:

1. Quote the denial reason (one sentence)
2. Respond directly with the evidence that answers it
3. Attach the documents and flag exactly where you’re citing it

What to include in your appeal packet

• Denial letter + reference number
• The plan’s criteria (if you have it)
• Fibrosis staging documentation (test report or biopsy summary)
• Relevant clinic notes
• Letter of Medical Necessity (recommended): diagnosis, staging, why Wegovy is appropriate for MASH, why delay is harmful, and why alternatives aren’t appropriate (if relevant). Get our template here!

If it’s a formulary appeal

• Clearly state this is a formulary exception request
• Include your prescriber’s supporting statement explaining medical necessity 

Request a second review (internal escalation)

If your first appeal is denied, request a second-level internal appeal (if your plan offers it). Make sure you address the new denial rationale directly.

External/independent review (when internal appeals fail)

For many plans, after a final internal denial you may be eligible for external review, where an independent reviewer decides the outcome—and the insurer must accept that decision. 

If your plan still won’t cover it

If you’ve exhausted your plan’s pathways, you can still explore:

• Employer benefits escalation (HR/benefits teams can sometimes clarify exceptions or push corrections)
• Manufacturer resources/savings programs (eligibility varies)
• Working with your clinician on interim management options while coverage is sorted (don’t delay care)

How Claimable helps

Navigating insurance is hard—especially when the denial reason doesn’t match your actual condition. Claimable helps you:

• Identify the most likely reason for denial
• Generate an appeal letter aligned to your denial reason and plan pathway
• Organize and submit the right documentation
• Escalate to the next level if the first appeal is denied

Start your Wegovy appeal with Claimable.

FAQs

What do I do if insurance denies Wegovy for fatty liver (MASH)?

Start by getting the denial letter and noting the exact reason (common language includes “not medically necessary” or “not on formulary”). Then appeal with a complete packet: MASH diagnosis, fibrosis staging evidence, supporting test results, and a clinician letter of medical necessity. If needed, request external review after final internal denial. 

Why did insurance deny Wegovy for fatty liver?

Common reasons include missing PA documentation, inability to confirm MASH + fibrosis stage, non-formulary status, or the request being treated under a broad GLP-1/weight loss exclusion instead of a liver indication. 

What does “not medically necessary” mean here?

It usually means the plan believes the documentation didn’t prove you meet criteria. Your appeal should focus on supplying the exact missing evidence (often fibrosis staging) and making it easy to verify. 

What is a formulary exception and when should I request one?

A formulary exception is a request for coverage when a medication isn’t on your plan’s formulary, or when you need a plan rule waived. These often require a prescriber’s supporting statement explaining medical necessity. 

Can I appeal if my plan says weight-loss drugs are excluded?

Often, yes—especially if the denial is misapplying a weight-loss exclusion to a MASH prescription. Your appeal should clearly frame the request as MASH treatment and include fibrosis staging documentation. 

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5 Key Takeaways from CEO Warris Bokhari on The Real Eisman Playbook

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Health insurance is supposed to make medical care predictable. But for tens of millions of Americans each year, it becomes the opposite: a source of uncertainty, delay, and financial shock.

In a recent episode of The Real Eisman Playbook, Claimable CEO Warris Bokhari joined host Steve Eisman for a wide-ranging conversation about health insurance denial rates, what’s driving them, and why the denial-and-appeal process often feels stacked against patients and providers. This post recaps the biggest themes from the episode – and what they mean for both healthcare workers and patients navigating care.

Note on sourcing: the statistics and examples below are presented as they were discussed in the episode and attributed accordingly.

What’s inside – and what surprised us

A few observations from Bokhari stood out, highlighting how the system of denials is complex and layered – going beyond just denying care.

• The AI denial problem goes deeper than it looks. Bokhari’s critique reveals that insurers can apply stale or poorly maintained policies at machine speed with AI, scaling old criteria and mismatched reviews faster than patients can respond.
  
  
• The system relies on you not fighting back. Bokhari argued that denial economics work because appeal rates stay tiny. If more people appeal, insurers face real cost and operational friction – quickly.
  
  
• Administrative delay is a strategy, not a side effect. Beyond initial denials, Bokhari described time-reset tactics that push payment further out and increase paperwork burden – especially crushing for small practices.

What are health insurance denial rates – and why do they matter?

Health insurance denial rates refer to the percentage of medical claims that are initially denied by an insurer. A denial can mean “not medically necessary,” “not on formulary,” “out of network,” “missing documentation,” or “needs step therapy,” among other reasons. Importantly, “denied” often doesn’t mean the care is inappropriate – it can mean the plan’s rules, paperwork, or policy logic blocked payment.

In the episode, Bokhari points to denial rates in the mid-teens on average (he references ~17%; other figures discussed vary by segment), and he highlights the scale effect: the U.S. processes roughly 5 billion claims annually, so a ~17% denial rate implies roughly 850 million denials in a year – impacting an estimated 70–90 million Americans.

5 key takeaways from the episode

1) Denials are a scale problem, not a rare exception

One of the strongest points from the conversation was sheer magnitude. Bokhari cited the U.S. processing roughly 5 billion claims annually and described how even a “mid-teens” denial rate becomes an enormous number of denied claims in practice – around 850 million a year – impacting an estimated 70–90 million Americans.

But his argument wasn’t limited to outright denials. He described a broader category of coverage friction that functions like denial in practice, interrupting care and payment even when the underlying treatment may be appropriate. These “deny-by-delay” tactics include:

• Shift delay / prompt-pay resets: insurers can request new information or submit an “edit” that resets the clock on when payment is due – extending the float and increasing paperwork.‍
• Predetermination: essentially prior authorization under another name – an added gate that may not guarantee coverage but still slows everything down.
• Clawbacks: care is approved and delivered, then months later the insurer reverses course and demands money back – creating major liquidity risk for providers.

Why it matters: when friction happens at scale, it becomes a population-level access barrier, not just an individual inconvenience. The result is delays for patients, administrative drag for providers, and a system that quietly shifts “care access” from clinical fit to coverage navigation.

2) Appeals can work – yet almost nobody files them

A core tension in the episode: denials may be common, but successful appeals can also be common. Bokhari referenced public reporting suggesting roughly ~50% of appealed denials can be overturned, while describing much higher outcomes in certain categories (including an anecdote from an insurance executive claiming extremely high overturn rates, and Claimable’s experience in specific areas).

Then came the headline problem: fewer than 1% of denied cases are appealed – because the process is confusing, time-consuming, and hard to manage while sick.

Why it matters: low appeal volume functions like “silent acceptance.” It allows friction to become a form of de facto cost control – without necessarily reflecting whether care is clinically appropriate.

3) AI is accelerating decisions—and scaling policy mistakes

The episode repeatedly returned to speed. Bokhari described claim decisions happening in seconds (he cites examples as fast as ~1.2 seconds) and argued insurers increasingly use automation to deny quickly – sometimes with logic that is outdated, inconsistently applied, or poorly matched to a patient’s situation.

His point wasn’t just “automation is bad.” It’s that bad policy applied quickly becomes a multiplier: the faster it runs, the more people it hits, and the more downstream rework it creates. 

Why it matters: faster denials don’t just arrive faster – they create cascading work: more paperwork, more resubmissions, more calls, more delays to treatment. That variability hits hardest in specialty and high-stakes care where timing matters.

4) Denial rates are tied to incentives—especially short-term risk vs. long-term illness

Bokhari offered a blunt framing: health insurance is often treated like a short-term financial product, while many medical needs are long-term realities. On the commercial side, he argued insurers may carry someone for roughly 18–24 months on average – job changes and plan switching—creating misaligned incentives when care is expensive and benefits accrue over years.

That incentive mismatch becomes especially acute as treatments improve (and cost more), including in oncology – something Bokhari says is increasingly showing up in what he’s seeing.

Why it matters: when incentives reward delay or denial, “coverage” becomes unpredictable at the point of need. Patients face uncertainty. Providers and hospitals carry working-capital strain. And employers – who ultimately fund a lot of this – often don’t realize how plans actually operate until a catastrophic case forces visibility.

5) If appeals rise from <1% to ~3%, the denial model starts to break

This was one of Bokhari’s most distinctive system-level claims: the denial/appeal equilibrium depends on appeals staying rare. He described appeals as operationally expensive for insurers (he cites internal conversations suggesting roughly hundreds of dollars per appeal to process, potentially far more when claim files or escalation are involved).

His broader argument: if you move appeals from less than 1% of denials to even ~3%, insurers can’t treat denials as cheap friction anymore. Processing burden rises, economics change, and blanket “deny fast” strategies become harder to sustain.

Why it matters: this reframes appeals as more than individual advocacy. If enough people appeal, it becomes a system lever – changing incentives, not just single outcomes.

Watch the full conversation

If you want the full context—including the personal stories, the incentive mechanics, and the discussion of how denial tactics spill into provider finance and consolidation—watch the episode here:

The Real Eisman Playbook featuring Claimable CEO Warris Bokhari (YouTube)

Closing thought

A denial can feel like a verdict – especially when it arrives quickly and without clear explanation. The episode’s larger point is that denial rates aren’t just an individual frustration; they’re a structural feature of how coverage operates today.

And when more people understand that appeals can work – and that higher appeal volume changes incentives—the system’s “deny fast, few fight back” equilibrium starts to weaken.

If you’ve faced a denial: you’re not alone—and you’re not powerless. 

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On July 1, CVS Caremark began forcing patients to switch from Zepbound to Wegovy – and we quickly took action to help folks fight back by appealing. With many patients protected by step therapy and non-medical switching laws, we were confident in their cases. The majority of these denials should have been overturned easily. 

They weren’t. 

Our team quickly started noticing an unusual – and troubling – pattern. Appeals were getting denied at a high rate and at unusual speed. Denials were coming back not in the standard hours or days, but in minutes – all following the same script and formula, returned with almost identical responses. Same wording. Same rationale. Same disregard for the patient’s actual medical needs.

Under federal law, every appeal is supposed to get a full, fair, individualized review by a human reviewer. These weren’t reviews. They were copy-paste auto-replies. This falls well outside of what we’ve been used to from insurers, and it raised serious legal concerns. 

Seeing the patterns in the data

The appeals process is typically fragmented, with individual patients and providers rarely compiling or comparing notes. Spotting trends is nearly impossible. But by handling hundreds of appeals specifically for CVS’s Zepbound forced-switch patients, Claimable had a unique vantage point. We saw systemic, policy-wide denials unfolding in real time. These weren’t a few isolated cases; we were seeing a consistent, repeated pattern of patients being denied their legal rights.

We immediately began supporting second-level appeals and escalation to independent review, including a detailed opinion from our Senior Legal Advisor, D. Brian Hufford, Esq., of The Hufford Law Firm PLLC, to help patients fight for the coverage they deserved.  More appeals began to succeed – but not nearly enough. 

Our success rate doubled after escalating cases with stronger legal arguments, but it remained below our usual benchmarks. That wasn’t good enough. We knew something was deeply wrong. So even while individual appeals were starting to work, it was clear that this broader pattern of systemic denials raised bigger legal questions – questions that went beyond what the appeals process alone can fix.

So with Brian, we began investigating additional options.

The CVS Caremark Zepbound lawsuit and your right to a full, fair, individualized review

Working closely with patients we’d supported through their appeals, Brian took the evidence to Berger Montague, a firm that specializes in healthcare class action litigation.

On September 3, 2025, they filed a class action lawsuit against CVS Caremark on behalf of patients in ERISA-governed employer-sponsored health plans whose coverage for Zepbound was denied and whose appeals were rejected based on medical necessity.

The lawsuit alleges that CVS Caremark wrongfully denied coverage by issuing denials that appeared to rely on templated language, despite patients meeting the plans’ criteria for medical necessity. Filed under ERISA, the suit alleges that CVS Caremark:

• Breached its fiduciary duties by prioritizing financial gain over medical appropriateness or plan obligations;
• Engaged in prohibited transactions by entering formulary agreements that benefit its own bottom line;
• Violated the terms of employer health plans by denying coverage for an FDA-approved, medically necessary treatment – while steering patients toward non-equivalent or off-label alternatives; and
• Ignored federal claims procedure standards by failing to provide timely, transparent, and individualized appeal reviews.

The complaint asks the court to issue injunctive relief, requiring CVS to change its policies going forward. It also seeks other appropriate equitable relief if those remedies are found insufficient to fully address the harm to patients. 

Advocacy doesn’t end with the appeal

Since July 1st, we’ve helped hundreds of patients file appeals for Zepbound denials. That’s only a tiny slice of the hundreds of thousands of patients affected. But it’s enough to spot the trend and push for accountability.

To be clear: Claimable isn’t a party to this suit. The relief it seeks isn’t on our behalf. But for us, being a patient-first company means taking a root cause approach to solving problems whenever possible. In this case, it meant going beyond the appeals process we operate within and connecting patients to legal options they might not otherwise access.

We built Claimable to make appealing easier and more successful. But just as importantly, we built it to expose what’s really happening behind the scenes. Denials don’t happen in isolation, and neither can our response.

That’s why we’re proud to support a broader movement for change, alongside legal teams, advocacy organizations, and policy leaders. Appeals are one piece. Litigation is another. Legislative reform is critical too. The only way to deter unjust denials is to challenge them—again and again—until insurers and pharmacy benefit managers face real consequences for saying no without cause.

What’s next for Zepbound appeals 

Legal action takes time, and we’ll be watching closely as this case makes its way through the courts. But while the system may be slow, we’re not slowing down. We will continue helping patients appeal these Zepbound forced switches – and we’ll keep evolving our strategies as new evidence and appeal precedents emerge.

We hope this lawsuit sends a clear message: insurer misconduct that puts patients at risk will not go unnoticed or unchallenged.

Our job isn’t just to make paperwork easier and arguments stronger. It’s to fight back when something feels wrong. To listen to patients. To advocate. To act.

And we won’t stop until everyone gets the care they need and coverage they deserve.

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Asthma isn't often thought of as a critical condition; but for many, access to medication for it is life-saving.

In 2024, Cole Schmidtknecht's insurance denied his steroid inhaler.  Shortly after, he suffered cardiac arrest induced by a severe asthma attack, and passed away following an ICU stay – just eleven days after he had to choose between paying his rent and picking up his prescription.

Since then, his parents Bil and Shanon Schmidtknecht have worked tirelessly to share Cole's story and advocate for the PBM reform that could have saved his life. In this letter, they share the real, human cost of asthma denials – and why giving people a path to coverage is so incredibly critical.

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Dear Claimable Team,

We're reaching out with deep gratitude and shared purpose – as parents, advocates, and people who know all too well what it means when access to asthma medication is delayed or denied.

Asthma is not a mild or temporary inconvenience – it is a chronic, life-threatening disease that requires consistent, uninterrupted access to prescribed medications. When an insurer denies coverage for a prescribed asthma treatment – whether it's a maintenance inhaler, rescue inhaler, or biologic – it is not simply a paperwork issue. It is a decision that can disrupt care, cause physical harm, and in the most tragic cases, lead to death.

Our son, Cole Schmidtknecht, died following a sudden asthma attack during one of the happiest times in his life. He had been fighting through the obstacles put in place by a broken healthcare system – including delays, denials, and unaffordable pricing. The denial of coverage for a medically necessary asthma medication can cost someone their life.

We live with that reality every day.

Appealing a denial is not just a bureaucratic step – it is a lifeline. When insurers reconsider their decision based on additional clinical context or urgency, they have the power to correct a dangerous mistake and prevent suffering. It's not only the right thing to do – it's a matter of life and death.

We want to extend our heartfelt thanks to each of you at Claimable for taking the initiative to bring asthma denial cases into your platform. Creating a simple, accessible path for patients and families to challenge harmful decisions is a powerful act of compassion – and a concrete step toward justice and accountability in healthcare.

Most importantly, we urge everyone – patients, caregivers, providers, and even insurers-to fight back when access to care is denied. Always appeal. Always ask questions. Always push for what is right.

Because every delay, every rejection, every barrier can cost someone more than just time – it can cost them their life.

Thank you for being part of the solution, and for honoring lives like Cole's through the work you do.

With gratitude,

Bil and Shanon Schmidtknecht

Patient Advocates

Patient Protector

Justice for Cole and All Others

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