When Insurers Say No to GLP-1s, We Help You Fight Back

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.