GLP-1 medications like Ozempic, Mounjaro, and Rybelsus have made incredible strides in how type 2 diabetes is managed. They’re more than just blood sugar meds – they help with weight loss, protect the heart, and improve long-term outcomes for millions of people living with chronic metabolic disease.

But even when you have a clear type 2 diabetes diagnosis, getting coverage for these medications isn’t always simple.

When it comes to GLP-1 prescriptions, patients are being denied. Not because they don’t qualify, but because insurers are putting up administrative roadblocks. Step therapy. A1C thresholds. “Missing” paperwork. Mandated programs. Short approval windows.

If this has happened to you, you’re not alone. And you’re not out of options. At Claimable, we’ve reviewed hundreds of real-world denials, dug deep into policy language, and built a fast, effective way to appeal – now available specifically for GLP-1 denials for type 2 diabetes.

Let’s dig into the denials. Here’s how insurance companies are making access harder—and how you can fight back.

You have a diagnosis. So why did they say no?

Diabetes is a lifelong disease, and treating it isn’t optional. So you’d think that having a type 2 diagnosis would be enough to get your GLP-1 covered – especially for drugs like Mounjaro and Ozempic that are FDA-approved to treat it. But often, it’s not.

Here’s what’s really happening: Insurers are moving the goalposts.

Even with broad coverage in commercial insurance plans (97% for Ozempic and 99% for Mounjaro, per GoodRX), insurers still deny access for reasons like:

• Step therapy requirements: Forcing you to “fail” on older, less effective meds like metformin, sulfonylureas, or insulin before approving a GLP-1 – even when those options don’t align with current ADA or FDA guidance.
• Arbitrary A1C thresholds: Denying you if your A1C is “too low” (even if you’ve been actively managing your diabetes), and keeping it out of reach with extreme A1C requirements not backed by evidence. We’ve seen A1C requirements as high as 8 or 9%, when the standard threshold is ≥6.5%.
• Documentation traps: Denials for “missing labs” even when they were submitted. Or for using initial criteria rules at renewal, which penalizes patients for improving.
• Mandatory diabetes programs: Insisting you enroll in programs like Teladoc or Omada before they’ll approve coverage – despite no ADA or FDA requirement to do so.
• Short-term approvals: Limiting authorizations to 1-3 months, even when your policy says 8-12 – forcing patients to constantly repeat paperwork and risk lapse if something goes wrong with an approval.

These aren’t medical decisions. They’re red tape designed to slow things down—or wear you out.

What happens next? You appeal the denial. And you can win.

Appeals work. Especially for diabetes. But the key is making your case the right way – backed by documentation, personalized to your health story, and targeted to your plan’s specific rules.

The strongest cases blend clinical studies, medical history, and the most up to date.

Here’s what we include in strong appeals to support GLP-1 coverage for type 2 diabetes:

• That you meet the criteria. Your diagnosis, your lab results (A1C ≥ 6.5%, fasting glucose ≥ 126 mg/dL, 2-hour glucose ≥ 200 mg/dL, or others), and your treatment history make a clear case for approval.
• Why step therapy doesn’t apply. We cite current clinical guidelines that support GLP-1s as a treatment for people with T2D, especially when weight, heart, or kidney concerns are present.
• Why rigid rules don’t reflect real care. Forcing you into a diabetes management program or denying based on an improving A1C ignores how chronic disease is actually managed.
• How your plan contract and relevant laws support coverage. Laws like ERISA, Section 1557 of the ACA, and state regulations protect your right to coverage. Plus, we review your plan in depth to make sure the insurer is in compliance with the policy they sold you (because denials often aren’t).
• What’s at stake. Your appeal can highlight risks of delaying care—like worsening blood sugar, increased cardiovascular risk, or medication lapses that undo your progress.

You don’t have to figure this out on your own. Claimable builds your appeal in minutes—so it’s easy to take action before the denial stalls your treatment.

Success isn't the end – it's just the start.

Even after you win an appeal, insurers may try to reimpose restrictions every few months. That’s why Claimable makes it easy to appeal, and re-appeal. 

Our simple platform allows you to create an appeal in minutes, not days, anytime you need one. And for renewals, we make sure to highlight your progress in your appeal – arguing that improvements like a lower blood sugar, blood pressure, or cholesterol, are strong reasons to continue coverage for your GLP-1.

We’re here to help you stay on the treatment that’s working—not restart the fight every time your insurer changes the rules.

The bottom line: Denied doesn't mean defeated.

You have a diagnosis. You have a prescription. You’ve done everything right. A denial doesn’t mean you don’t qualify—it means the insurer is hoping you’ll give up.

At Claimable, we’re here to make sure you don’t.

Whether it’s Ozempic, Mounjaro, or Rybelsus, we’ll help you build a clear, effective appeal – personalized to your diagnosis, your plan, and your rights. No paperwork. No hold music. Just a smarter, faster way to fight back.

Because your diabetes care shouldn’t hinge on red tape.

Because chronic disease deserves continuous support – not constant obstruction.

Because one denial shouldn’t be the end of your story. Let’s get you covered.

Start your appeal today.

December 2025 update: This article was originally written in summer 2025 when CVS Caremark notified patients about a switch from Zepbound to Wegovy. Now, as plans renew for 2026, many people are receiving similar updates – Zepbound will no longer be on their formulary in the New Year. The good news? You can still submit a formulary request to keep coverage for Zepbound. Learn more about past formulary changes in this article, check out more on our Zepbound appeals here, or get started today.

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Starting July 1, 2025, CVS Caremark will stop covering Zepbound – even if it’s been working for you. Thousands of patients with conditions like obesity, obstructive sleep apnea, and other conditions are being notified that they must switch to Wegovy to stay covered. 

If you received a letter saying your coverage is changing, you’re not alone. And you have options. What’s happening here is called a “formulary change”, and while it may seem final, you can appeal – and win.

At Claimable, we help people fight insurance denials every day – which means this isn’t our first forced switch, and it won’t be our last. Read on for our guide on what you need to know, why it matters, and exactly how to push back to stay on the medication that’s working for you.

Quick Summary: What you need to know

• CVS Caremark is removing Zepbound from its formulary starting July 1, 2025
• Patients will be required to switch to Wegovy, even if Zepbound is working
• You have the right to appeal this switch, and federal law requires a decision in 72 hours
• Zepbound and Wegovy are not interchangeable – Zepbound may work better for some patients, especially those with OSA
• Claimable is building a tool to help you appeal your Zepbound denial quickly and effectively

Why is CVS Caremark suddenly denying Zepbound?

CVS Caremark, owned by CVS Health, is one of the largest pharmacy benefit managers (PBMs) in the country. They recently struck a deal with Wegovy’s manufacturer, Novo Nordisk, to make Wegovy the “preferred” GLP-1 medication on its formulary. As a result, Zepbound is being dropped from coverage starting July 1, 2025, even for patients already using it with good results.

This change isn’t about safety or effectiveness. It’s about money. PBMs negotiate rebates with drugmakers, and these behind-the-scenes deals often determine which medication you can get – regardless of what’s best for patients.

What does formulary change mean?

A formulary is the list of medications your pharmacy benefit manager (PBM) or insurer agrees to cover. When a drug, like Zepbound, is removed from the formulary, your insurance will no longer pay for it – even if it was previously approved and is working well for you.

Changes to your formulary affect your coverage – not your pharmacy. Whether you fill your prescriptions at a CVS pharmacy or elsewhere, you’ll be denied coverage for Zepbound everywhere starting July 1 unless you appeal, which means it’s time to understand what’s changed, and make an action plan.

While Zepbound is on the out, Wegovy isn’t the only GLP-1 that CVS Caremark is covering. Here’s a snapshot of what CVS Caremark will and won’t cover under its updated formulary: 

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Why It Matters

Zepbound and Wegovy are not interchangeable. Zepbound uses a different mechanism of action (dual action GIP/GLP-1 receptor agonism), which means it may be more effective, and is often better tolerated – especially for people with specific conditions like obstructive sleep apnea (OSA). And older medications included on the CVS Caremark formulary – like Saxenda, Qsymia and Orlistat – are far less effective and not considered equivalent medications.

Forced switching when you’ve reached a stable, effective dose isn’t just frustrating – it’s disruptive and medically risky, potentially causing:

• Weight regain or return of symptoms
• New, intolerable, side effects
• Health setbacks and scares
• Extra clinician visits and increased costs

At Claimable, we believe your care plan should be based what’s medically best for you, as determined by your doctor – not what saves your PBM money.

What to do if Zepbound is denied

If your Zepbound prescription is denied, you can file a formulary exception appeal. And in many cases, insurers are required to honor that appeal if your doctor says switching could harm you.

Here’s exactly what to do.

Step 1: Get a refill before July 1 

Request a 90-day refill or 30-day vacation override before July 1 (if allowed by your plan) to give you a buffer while your appeal is reviewed. This will help you avoid a care gap.

Step 2: Talk to your doctor

Reach out to your doctor now so you’re ready when the July change kicks in. Ask them to:

• Be ready to file a new prior authorization for Zepbound on or after July 1.
• Write a letter of medical necessity if you decide to file your own appeal.

Step 3: File your appeal

Starting July 1, your claim for Zepbound will be denied. Once that happens:

• Submit a formulary exception request. 
  • This can be submitted by you or your doctor, but we recommend submitting the appeal yourself with your doctor’s Letter of Medical Necessity attached. Patient appeals often have more legal rights and require responses from the insurer on faster timelines.
• This tells the insurer that Zepbound is medically necessary for you.
• Insurers must respond within 72 hours under federal law.

Less than 1% of people appeal denied claims, but those that do win about 50% of the time. You can boost your odds by following our tips below – or by using our custom tool to build the strongest possible appeal for you.

What to Include in Your Appeal

For the best chance at winning, submit an appeal letter requesting a formulary exception that explains why switching could harm you.

A strong appeal letter should include:

• Your medical results on Zepbound (weight loss, symptom control, etc.)
• Any prior medications that you’ve tried and failed
• Specific medical conditions like OSA that Zepbound uniquely treats
• A letter from your doctor supporting continued use
• Clinical studies, applicable laws and insurance regulations, and precedents from successful appeals with similar cases to yours
• Supporting evidence like lab results, weight logs, dosing history and medical records

Your appeal should make the case that Zepbound is working for you and that you want to avoid disruption to a stable, effective treatment plan – and be backed up by solid documentation.

Your legal rights to appeal

Under federal law, you have the right to request a medically necessary exception when a formulary change puts their care at risk.

Federal Law: 45 CFR § 156.122(c) “A health plan providing essential health benefits must have a process in place that allows an enrollee, their designee, or prescribing provider to request access to a clinically appropriate drug not otherwise covered by the plan. If granted, the plan must treat the excepted drug as an essential benefit and must respond within 72 hours.” View the regulation →

On top of federal protections, many states have laws preventing insurers from forcing stable patients to switch medications mid-year. These non-medical switching or continuity of care laws may guarantee:

• You can’t be forced to switch if the medication is working.
• Your doctor can override the change with a written statement.
• You must get advance notice and a clear process to stay on your current drug.
• When an exception is granted, your copay and coverage tier must stay the same.

Check here to see the non-medical switching laws enacted in your state – especially if you live in California, Illinois, Texas, or another protected state.

What to do if you get denied again

If your first appeal is rejected:

• File a second-level appeal or request an external medical review, depending on what the denial says is your next step. You have a right to multiple appeals and many people win and the second try, especially when an independent reviewer is involved.
• File a complaint with your state’s Department of Insurance, especially if they refuse to give you a timely decision or fail to have a qualified clinician give you a full, fair review.
• Let your employer know—they can override the PBM if you’re on a self-funded plan.

CVS has tried this before – and patients fought back

In 2022, CVS removed the life-saving blood thinner Eliquis from its formulary, forcing 150,000 patients to switch. After public outcry, provider backlash and reports of serious strokes and heart attacks, they reversed course. 

We believe they can – and should – do the same here. We encourage you to consider signing the petition demanding they reverse the policy.

Create the strongest possible appeal, the easy way

From the right clinical studies to specific appeal precedents that apply to your unique circumstances, at Claimable we know how to fight – and win – forced switches like these. 

Our fast, affordable tool helps you fight back. Our platform:

• Creates a personalized appeal letter backed by evidence
• Walks you through the process step by step, so you can get your appeal done in minutes, not days
• Compiles and ships your appeal not just to your insurer, but to other relevant parties like your state’s Department of Insurance, HHS, and others – so your insurer knows you mean business.

Frequently Asked Questions

Does CVS Caremark cover Zepbound? No. As of July 1, 2025, Zepbound is being removed from the CVS Caremark formulary.

Can I appeal the switch to Wegovy? Yes. You have the legal right to request a formulary exception for medical necessity.

Is Wegovy the same as Zepbound? No. Zepbound uses dual GIP/GLP-1 action and may work better for some patients.

Will Medicare cover Zepbound? Aetna Medicare plans often exclude weight loss drugs like Zepbound. Appeals here may be more difficult, but not impossible.

Final Word: Your Care. Your Rights.

If Zepbound works for you, you have every right to fight for it. Forced switches driven by rebates, not results, are wrong. Claimable is here to help you fight back.

Start your appeal now to protect your care.

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Annual Awards Recognize Innovative Companies and Projects Addressing the World’s Most Urgent Challenges

Recognition Follows Claimable’s Launch of GLP-1 Support, Helping Patients Navigate One of the Most Denied Treatments in the U.S.

Sacramento, CA - [June 10, 2025] - Claimable is proud to announce that it has been named to Fast Company’s 2025 World Changing Ideas Awards list. This annual recognition honors bold and transformative efforts that tackle the world’s most pressing issues—from fresh sustainability initiatives and cutting-edge AI developments to ambitious pursuits of social equity helping mold the world. 

Every year, 850 million healthcare claims are denied, forcing millions of Americans to choose between medical care and financial stability. Claimable is tackling this healthcare crisis with the first AI-powered appeals platform, helping patients and providers fight back against unjust denials. Patients upload their denial notice and insurance information, answer a few questions, and Claimable does the rest, analyzing clinical research, policy details, appeals data, and their unique medical story to generate and submit a customized appeal in minutes.

This year’s awards showcase 100 outstanding projects. A panel of Fast Company editors and reporters selected the winners from a pool of more than 1,500 entries and judged applications based on their impact, sustainability, design, creativity, scalability, and ability to improve society.

“The World Changing Ideas Awards have always been about showcasing the art of the possible,” says Fast Company editor-in-chief Brendan Vaughan. “We’re proud to recognize the organizations and leaders that are making meaningful progress on the biggest issues of our time.”

Since launching in late 2024, Claimable has recovered nearly $6 million for patients, boasting an over 80% success rate across more than 70 commonly denied treatments, including autoimmune and migraine medications, IVIG for children with PANS/PANDAS, and now GLP-1s for obesity and type 2 diabetes. For the millions facing treatment delays or crushing medical debt, Claimable offers hope, making the appeals process simple, fast, and effective, getting patients the care they deserve.

“We’re using AI to solve a deeply human problem,” said Claimable Co-Founder and Chief AI Officer Zach Veigulis. “Fast Company’s recognition reinforces what we’ve always believed at Claimable, that AI can be used to make life better. At a time when technology is often used to cut costs and deny care, we’re proving it can expand access and return power to patients.”

This recognition comes as Claimable expands its impact with support for GLP-1 medication appeals. One of today's most denied treatment categories, GLP-1s like Ozempic, Mounjaro, Zepbound, and Wegovy have transformed care for people with obesity and type 2 diabetes. However, patients are often denied access due to formulary exclusions, overly restrictive eligibility criteria, or insurer mandates to “fail first” on older or less effective treatments. With over 137 million U.S. adults now eligible for GLP-1 support, Claimable offers patients and providers a purpose-built solution designed to overcome the unique challenges of GLP-1 coverage denials.

"Insurance denials aren't just a paperwork issue, they're a public health crisis hiding in plain sight," said Alicia Graham, co-founder and COO at Claimable. "While others patch old systems, we're building something entirely new. We're reimagining how healthcare access should work, using technology to turn the tables on a system that's stacked against patients. That's why we've built Claimable alongside the people most affected: patients and providers. Our platform works because it doesn’t just make appeals faster, it makes them smarter, giving people the best chance to win."

Claimable is available nationwide and accepts denials from all insurance providers, including Medicare, Medicaid, United Healthcare, Anthem, Aetna, Cigna, and BCBS plans. To learn more about Claimable and all the treatments they support, visit www.getclaimable.com. 

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ABOUT CLAIMABLE

Claimable revolutionizes the way patients and providers fight healthcare denials, helping ensure everyone has access to the care they need and the coverage they deserve. The platform leverages purpose-built AI to analyze clinical research, policy details, appeals data, and patients’ unique medical stories, generating and submitting customized appeals in minutes. Claimable is available nationwide, accepting denials from all insurance providers, including Medicare and Medicaid. A NVIDIA Inception Program member, Claimable continues to push the boundaries of AI innovation in healthcare. For more information: www.getclaimable.com.

Contact:

Emily Fox

press@getclaimable.com

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At Claimable, we believe healthcare should reflect the best of what we know—not be constrained by inertia, stigma, or financial incentives that prioritize profit over patient care. 

Right now, that belief is being tested. Patients eligible for GLP-1 medications are being denied coverage—denials often based on arbitrary criteria that ignore clinical guidelines and FDA approvals. As the science accelerates, coverage is moving in the opposite direction—not because the evidence has changed, but because the rebate math doesn’t work for payers. 

That’s why we’re expanding our platform to support appeals for  GLP-1s. We already know that the conditions they treat are urgent—affecting over half of US adults and driving a disproportionate share of preventable healthcare costs—and with compounded versions of these medications unavailable as of May 22nd, the need is more pressing than ever.

What the science is telling us

GLP-1s have evolved far beyond their original use for type 2 diabetes and weight loss. Today, they are FDA-approved not only for managing blood sugar and reducing body weight, but also for treating obstructive sleep apnea and lowering the risk of serious cardiovascular events like heart attacks and strokes.

In advanced stages of clinical review, GLP-1s are also showing promise for treating metabolic dysfunction-associated steatotic liver disease (MASLD), chronic kidney disease (CKD), pre-diabetes, diabetic retinopathy and osteoarthritis of the knee (in patients with obesity).

And the emerging science is even more far-reaching. Early research suggests that GLP-1s may play a role in reducing neuroinflammation associated with Alzheimer’s, Parkinson’s and dementia; curbing addictive behaviors tied to substance use; improving symptoms of irritable bowel syndrome (IBS), and even impacting certain types of cancer. The list of ways these medications can change — and save — lives is profound and growing fast.

For many of us, this isn’t just promising science. It’s deeply personal.

One area that strikes particularly close to home for me is metabolic dysfunction-associated steatotic liver disease (MASLD) —a condition that affects nearly a third of U.S. adults and has no approved treatment. I lost my father to complications of diabetes, including MASLD. By the time he was diagnosed, he was already suffering from liver failure. A catastrophic upper gastrointestinal bleed and emergency medical evacuation followed. It was marked by a single week that aged me years.

If therapies like this had been available earlier—maybe it would have changed the outcome.

These medications don’t just improve quality of life — they help prevent the cascade of complications that make care more expensive, less effective, and harder to access. A recent analysis of over 50 million insured lives found that GLP-1 users experienced 44% fewer hospitalizations for major cardiovascular events, and healthcare spending rose at just half the rate of similar non-users by year two.

When people stay healthier longer, it means fewer emergency interventions, fewer disability claims, and more stable, productive lives.

As new treatments emerge, access to GLP-1s is slipping away.

GLP-1s are no longer just a type 2 diabetes or weight loss drug. They represent a platform therapy with far-reaching potential across some of the most costly, intractable diseases in healthcare—and yet, access is moving in the wrong direction.

Statins. Insulin analogs. SGLT2 inhibitors. Each faced early resistance. Each is now a pillar of care. GLP-1s are on the same trajectory—but patients can’t afford to wait years for coverage to catch up.

The barriers to coverage aren’t scientific. They’re systemic. And these delays and denials don’t just hurt patients. They affect providers, employers, and the healthcare system as a whole.

With compounded versions of branded GLP-1s off the market as of May 22, 2025, affordability has collapsed. Direct-pay options run $400 to $700 a month—pricing out the majority who should qualify for initial or continued treatment. Copay cards and assistance programs offer temporary relief—but they’re not available to everyone, and they don’t solve the broader access problem. 

Those who attempt to gain coverage face increasingly restrictive and often arbitrary criteria. From BMI requirements that far exceed standard criteria, to mandating costly weight management programs and shrinking approval windows from 12 months to just one, new barriers are being constantly invented and implemented to limit access.

Turning evidence into access—one appeal at a time.

At Claimable, we help patients push back. We handle the administrative burden—challenging denials, navigating appeals, and ensuring every request is grounded in current science, regulatory precedent, and standard of care.

GLP-1s are the next frontier in chronic disease prevention. But for patients to benefit, access must match the evidence.

The dream is to prevent people from becoming patients, to keep them present in their lives.

We’re here to make that happen— appeal by appeal. We’re ready to go.

Warris Bokhari

CEO, Claimable

We’re in the middle of a major shift in how we treat obesity, diabetes, and metabolic disease. GLP-1s have changed the game. But as usual, the people who need these medications most are being blocked—not by science, but by insurance red tape.

Coverage decisions vary wildly—and they’re changing fast. What your plan covers today might change next quarter. What was approved for a friend may be completely denied for you. Some plans require extreme BMI thresholds. Others won’t count progress if you paid out-of-pocket. And many still exclude GLP-1s entirely for weight loss, regardless of your health risks or clinical need.

Over the past several months, we’ve dug deep into this rapidly developing landscape—reviewing hundreds of real-world denials, studying shifting coverage criteria, and collaborating with patients, providers, and advocates to understand what actually works when it comes to securing insurance coverage for GLP-1s. We’ve built an appeals system that not only reflects the reality of this fight—but helps people win it.

No paperwork. No hold music. No fax machines. Just a simple, powerful way to get your appeal in motion—with the right evidence, the right strategy, and into the right hands. So you can get back to focusing on what matters: Your health.

Read on for the most common challenges with GLP-1 coverage, and what you can do if you get denied. And if you haven’t already, you can read more about why this medication matters in this letter from our CEO.

Common GLP-1 Coverage Questions (And How We Help)

• How do I qualify for a GLP-1 prescription?
• Why did my insurance stop covering my GLP-1 after it was working?
• Can I switch from a compounded GLP-1 to a brand-name one?
• What can I do if my insurer forces me to switch medications?
• My plan says GLP-1s aren't covered - can I still appeal?

Getting Coverage for a New GLP-1 Prescription

The challenge: Insurers often require you to meet extreme and unreasonable criteria, which can feel like an impossible bar to clear. 

Whether you’re starting Wegovy, Zepbound, or Mounjaro, getting your first prescription covered can feel like hitting a moving target. That’s because more than half of all plans with GLP-1 coverage apply criteria that are more restrictive than FDA guidelines— and criteria are changing every few months.

Some plans require BMIs as high as 40 (when the FDA standard for eligibility is 30) or multiple co-morbidities like cardiovascular disease, hypertension and obstructive sleep apnea. Others demand months of participation in a costly weight management program before considering medications. Many limit approval to just a few months, with no guarantee of continuation. And some plans require you to fail on ineffective treatments before they’ll cover what actually works—which could put your health at risk.

How we fight it:

A clear, evidence-backed appeal, personalized to your unique health story and insurance policy, is key to getting coverage. When you appeal through Claimable, we  show:

• How you meet the standard criteria: BMI, A1c, co-morbidities, lifestyle changes.
• Why restrictive requirements—like excessive documentation or arbitrary program rules—don’t reflect medical necessity, clinical standards or applicable laws.
• Why step therapy or “preferred” drugs aren’t safer or better for you.

A denial doesn’t mean you don’t qualify. It means the insurer wants you to give up. With the right appeal, we’re here to make sure you don’t.

Continuing Coverage When You're Making Progress

The challenge: Once you see success on a GLP-1, insurers can use it as justification to stop covering you.  

When a GLP-1 is working, you know it: weight is coming down, blood sugar is steady, and related conditions—like high blood pressure or sleep apnea—are improving. But instead of that progress ensuring continued access, insurers often use it as a reason to demand new paperwork—or worse, to cut you off.

FDA guidance allows up to a year to demonstrate a 5% weight loss. But some plans push for three times that weight loss in one-third the time—setting unrealistic, and potentially unsafe, targets that deny care despite clear clinical benefit. Insurers claim your progress means you no longer need treatment. And if your GLP-1 journey hasn’t been a straight line, your coverage could disappear altogether.

That’s where we come in.

How we fight it:

We’re here to make sure your progress counts—and keeps counting. Claimable’s continuation appeals includes four key arguments to keep you on track. 

• Highlight your progress—weight loss, A1C improvement, better sleep, lower blood pressure, and other real clinical gains.
• Clarify gaps and changes—like switching from compounded meds, adjusting your dose, or managing prior authorization delays.
• Hold insurers accountable—to medical guidelines, continuity of care protections, and coverage terms that support ongoing treatment.
• Ensure your plan follows fair, consistent policies—challenging short approval windows, moving goalposts, and arbitrary rules that ignore your rights.

If your medication is working, you shouldn’t have to fight harder just to keep going.

Switching from Compounded To Brand-Name

The challenge: As of May 22, 2025, compounded copycat GLP-1s are off the market. Getting covered for the branded version of your exact same meds? Not so easy.

While branded GLP-1s were in shortage, many compounding pharmacies offered lower-cost alternatives that proved to be very popular, with an estimated 2-4 million Americans prescribed a compounded GLP-1. Now that the FDA-declared shortage has ended, those pharmacies are no longer permitted to produce copies of brand-name drugs like Wegovy or Zepbound.

Compounding pharmacies can still prescribe and produce custom formulations when medically necessary, but these medications come with risks. They don’t go through the same rigorous safety and efficacy testing as FDA-approved drugs, which means they could increase health risks or be less effective.

Now, many patients are being told they don’t qualify for coverage of a branded GLP-1 — even if they would have qualified initially and the compounded version was working well.

Common barriers include:

• You’ve already lost weight and no longer meet the starting BMI requirement.
• Your insurer won’t count your cash-pay or compounded treatment history.
• You’re using a GLP-1 to manage conditions like sleep apnea or cardiovascular disease — and insurers are ignoring the full picture.

How we fight it:

We build personalized appeals to make your case — showing medical necessity, continuity of care, and the real-world value of staying on treatment. Your right to access a compounded medication during the shortage was protected. Your full medication history should count now, too.

You shouldn’t have to start over — or pay $400 to $700 out of pocket — just because the rules changed.

Fighting Forced Switches

The challenge: You know what works. Your insurer wants to change it.

More and more patients are being forced to switch GLP-1 medications—not because of medical need, but because insurers want to cut costs or capture rebates. These non-medical or formulary switches happen when a payer—not your provider—chooses your medication based on their bottom line.

For example: CVS Caremark recently dropped Zepbound from its formulary, pushing millions of patients to switch to Wegovy starting July 1.

These switches often have nothing to do with your health, and sometimes they don’t even lower your costs. Instead, they can disrupt care, increase side effects, and lead to worse outcomes.

GLP-1 medications in particular are sensitive to disruption. Patients and providers often spend months carefully titrating to the right dose. Restarting with a new medication can trigger setbacks, new side effects, and reduced effectiveness. And medications like Zepbound and Wegovy aren’t interchangeable—they have different mechanisms of action, indications, and side effect profiles.

If your current GLP-1 is working and well-tolerated, there may be no clinical reason to change. That decision should stay between you and your provider—not your insurer.

How we fight it:

Claimable helps you push back with a personalized appeal—built to preserve the treatment that’s working for you (and your wallet). Our forced-switch appeals:

• Make a continuation of care case, showing how switching could harm your progress,especially with medications that require careful titration.
• Highlight clinical differences between your current and proposed medication to demonstrate they aren’t interchangeable.
• Surface real-world evidence of your stability, symptom improvements, and the risks of disruption.
• Challenge the lack of medical justification for switching patients who are stable and responding well.
• Frame fiduciary risks under ERISA for the majority of employer-based plans that are self-funded.
• Flag legal and ethical concerns, particularly in states with protections against non-medical switching.

How to Appeal Plan Exclusions or “Not Covered”

The challenge: More and more plans are excluding GLP-1s from coverage.

If your denial says weight loss medications are “not a covered benefit,” you’re likely dealing with a plan exclusion—one of the hardest types of denials to fight. These exclusions are written directly into your insurance contract, often banning coverage for weight loss medications across the board—or blocking specific drugs like Zepbound or Wegovy—regardless of medical need.

The tough truth? About half of all health plans exclude GLP-1s for weight loss.

The silver lining? Most people with obesity also have another condition that GLP-1s are approved to treat—like type 2 diabetes, cardiovascular disease, or sleep apnea. And new FDA indications are being added all the time.

How we fight it:

Even if your plan excludes weight loss treatment, there are still ways to push back:

• Resubmit with a different diagnosis, if one applies.
• Request a formulary exception, especially if no equivalent alternative exists.
• Ask for a continuation of care exception, especially if you were previously covered—many states require it.
• Ask your employer to change or override the policy if you’re on a self-funded plan. 
  Tip: Most large employers self-fund their plans, which means leadership—not the insurer—has the final say and a fiduciary duty to act.
• File a complaint or consult a lawyer if your plan was misleading during enrollment.
  Tip: Misrepresentation, breach of contract, or unfair practices may violate consumer protection laws

These appeals are harder to win—but not impossible. And the policy landscape is shifting fast. Lawsuits, new guidance, and growing public pressure are forcing insurers to reconsider blanket exclusions.

The Bottom Line

GLP-1 medications are transforming lives—but too often, access depends on your paperwork, not your progress or potential.

Insurers are hoping the red tape wears you down. That you won’t appeal. That you’ll switch, stop, or give up.

At Claimable, we’re here to make sure you don’t.

Whether you’ve been denied, dropped, or told you’re not covered, we’ll help you fight back—with expert strategies, AI-powered tools, and appeals tailored to your unique medical story and your plan’s real rules.

Because you deserve access to the treatment that’s working.

Because your health shouldn’t hinge on fine print.

Because one denial shouldn’t be the end of your story.

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We get asked all the time for tips on how to write an effective Letter of Medical Necessity (LOMN). It’s one of the most critical tools in challenging an insurance denial, yet many providers aren’t sure what makes a letter truly persuasive.

After reviewing hundreds—some that succeeded, others that failed—we started to see clear patterns in what works and what doesn’t. A well-crafted LOMN isn’t just about paperwork; it’s a powerful tool to make insurers recognize what providers already know: the treatments you prescribe aren’t optional, they’re necessary.

That’s why we put together this guide: to help providers make that case clearly, confidently, and successfully.

What is a Letter of Medical Necessity?

A LOMN is a formal document from the treating provider explaining why a treatment, medication, or service is medically necessary. It can serve as a provider appeal on its own or support a prior authorization request or patient appeal.

Why the Letter of Medical Necessity Matters

A LOMN can be the deciding factor in whether a patient gets the care they need. 

When making coverage decisions, insurers often rely on reviewers with limited or no expertise in the condition, a history of concerning decisions, and no insight into the patient’s history—yet they make life-changing decisions in minutes. Investigations have shown that providers and patients who appeal more frequently face fewer denials over time. By challenging every unjust denial, you fight for your patient’s care today and help prevent future denials.

An effective LOMN establishes your authority as the treating provider, documents the patient’s relevant medical history, and presents clear clinical justification for why the treatment is essential—dramatically improving the chances of approval.

Let’s break down exactly what makes a LOMN effective—and how to write one that insurers can’t ignore.

How to Write a LOMN That Gets Results

When a prior authorization or appeal is needed, act quickly. A clear, structured LOMN can make all the difference. Here’s how to do it:

1. Review the Criteria: Examine the insurer’s coverage criteria or the specific denial  reasons to identify what must be addressed in the letter.
   
2. Initiate the Process: Inform your patient that a LOMN will be part of the appeal and discuss any additional details that could strengthen or expedite the case.
   
3. Gather Key Information:  Gather medical records, clinical studies, and relevant guidelines to build a strong, evidence-backed argument.

Essential Components of an Effective LOMN

To ensure your LOMN is impactful, include these key sections:

• Introduction: Briefly state your credentials and role in the patient’s care to establish expertise. Highlight your direct involvement in diagnosis, treatment planning, and ongoing management.

• Diagnosis: Clearly state the diagnosis, how it affects daily functioning, and why specific codes matter. If applicable, note progression or complications that make timely treatment essential. Specify how the patient meets standard clinical criteria.
• Medical History: Summarize past treatments, including durations, outcomes, and why they were ineffective. If any treatments were discontinued, specify the reasons (e.g., side effects, lack of efficacy). Address needed exceptions to step therapy.
  
• Necessity of Treatment: Explain why this is the most appropriate (or only) option, considering medical necessity, patient-specific factors, and cost-saving benefits for patients and insurers/employers. (See example: CSRO Letter on White Bagging) 
  
• Non-Standard Criteria: Call out insurer policies that use non-standard criteria that contradict clinical guidelines. For example, denying the only FDA-approved treatment for patients with rheumatoid arthritis or cancer.
  
• Supporting Evidence: Include relevant medical records, lab results, and imaging. Reference clinical guidelines and peer-reviewed studies to strengthen your case and ensure the latest research is on record for future appeals and legal action.
  
• Urgency: Highlight risks of delaying treatment, particularly if deterioration or irreversible harm is likely. If relevant, include studies showing long-term consequences of delayed care.

Did you know? You can request a 72-hour expedited appeal if a delay risks your patient’s health. Your LOMN must state the urgency and document at least one risk factor, such as hospitalization, severe pain, ongoing care, disability risk, or time-sensitive treatment. Some states, like Illinois, broadly define urgency, including impairments to maximal function.

Final Thoughts

An effective LOMN not only strengthens your patient’s appeal but reinforces your role as the expert on their care. It’s a powerful tool that forces insurers to recognize the real-world impact of their decisions. By laying out the necessity of treatment in clear, compelling terms, you make it harder for them to justify a denial. And by challenging every unjust denial, you help create accountability—making insurers less likely to deny necessary care in the future.

At Claimable, we believe everyone should get the care and coverage they deserve. That’s why we’ve built tools to help providers challenge denials faster and more effectively. If you’re ready to take control of the appeals process, join us.

Ready to empower your practice and transform how you handle appeals?

Sign-up now for more expert resources and join our community of forward-thinking providers.

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