The first responses to Zepbound appeals for the CVS Caremark forced switch have started to come in. Claimable COO Alicia Graham breaks down what's in these new denial letters, and what that means next.

If you've gotten one of these letters, know that we're going to keep fighting it. We don't believe this rationale is based on medical necessity, nor that it will hold up to a secondary review. We're actively escalating these appeals, because we believe that you will win.

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This thing is getting more ridiculous by the day. As we start to see responses come back to CVS Caremark, I wanted to share what we've been seeing – because frankly, a lot of what they’ve said so far is vague, misleading and even straight up false. I don't believe these denials are in compliance with the plan policy, applicable laws, or clinical standards of care at all, and we're going to break down why that Is.

This is my take on exactly what’s in these denial letters, what it actually means, and what you can do if you got one. I know how confusing this is, and I hope this can help anyone navigating it.

The one size fits all “coverage request was not approved” denial letter

First of all, this is the language we’re seeing in almost all of these letters – just copy-pasted for everyone. By law, each appeal needs to be reviewed by a qualified human performing a full and fair review of specific case facts… so straight off the bat, it doesn’t look like they’re doing that.

“Your appeal for Zepbound has been determined as not medically necessary”

They say that current medical literature doesn’t support the use of Zepbound over the available formulary alternatives. Except it does (here's the head-to-head study we’ve been including in our appeals). They conveniently don’t include the studies they use to make their decision, which they’re supposed to do… so we have no idea why they ignored it and what they are using instead.

Plus, they’re saying Zepbound isn’t medically necessary, but Wegovy and Mounjaro are?! I don’t understand how that argument could ever stand up in a court. Wegovy is indicated for the same treatment with same coverage criteria, and Mounjaro... isn’t even indicated for weight loss.

“The primary covered drug for your plan is Wegovy”

“If the patient is unable to take the primary covered drug, chart notes must be submitted to CVS Health”. What they’re saying here is if you fail Wegovy, you could get back on Zepbound. This is step therapy, but in lots of states there are laws against this. If you live in New York, for example, they cannot require you to have previously failed Wegovy – but we’re seeing them do it anyway.

If you live in New York and got this, you should definitely fight it.

“The secondary covered drug for your plan is a tirzepatide product [Brand Mounjaro]”

This is a curveball – not what we expected to see. Yes, Mounjaro is a tirzepatide like Zepbound, but per the FDA it is only approved for type 2 diabetes.

If you and your doctor agree on you taking Mounjaro off-label, great! That’s completely up to you and what’s best for your care. But for your insurer to try to force you onto an off-label indication? Unethical, clinically absurd, and probably illegal.

But even more importantly this smells like a trap to me.

The trap: “Formulary alternatives may still require a clinical prior authorization”

They’re saying that Mounjaro may still require a PA. We’ve seen this before, so I want patients and providers to clearly understand the risk of going down this path.

The PA form states you do not qualify for Mounjaro unless you have type 2 diabetes, so the minute they ask for a PA your Mounjaro coverage will be gone. Even if they approve you without a PA today, at any time they can come back ask for it which will kick you off.

This has happened to several patients we’ve worked with who took Mounjaro for months and then were told they don’t qualify. They can force you off at any time because the criteria for Mounjaro is different.

The trap within the trap: The 180 day appeal window

I think a big part of them trying to lure you into doing Wegovy or Mounjaro is that by law, you only have 180 days to appeal your Zepbound denial. Hypothetically they could cover Mounjaro for those 180 days, and then on day 181 when that window expires and you’ve lost your right to fight for Zepbound, revoke your approval for Mounjaro – leaving you with nothing.

Even if you want to try Wegovy or Mounjaro, I would keep going on your Zepbound appeal at the same time. If you win a Zepbound appeal, they can’t just take it away.

Robocalls, app messages, and other nonsense

Legally, they have to send you a formal letter with details, full appeal rights, and more. But instead, they’re sending these mini-messages ahead of time and telling you to wait for the letter.

Why? Because not having all the info makes your response weaker and slows things down. Make sure you request your full claim file, formal denial letter, drug policy and all other decision documents. You’re legally entitled to them.

The bottom line: You don’t have to let them win

The TLDR; these denials don’t pass my smell test for compliance with the plan policy, applicable laws, or clinical standards of care. I don’t think these will hold up in external review, courts, or with regulators. So I say keep fighting.

If you got one of these, first request all the documents. Then, escalate it. In your denial letter there will be a number/address for the external reviewer to send it to. **You have the right for an external review and I think that if you do you will win.

At my company this is exactly what we’re doing. We’re creating secondary appeals that address every single piece of BS in these letters and escalating them to reviewers and regulators. Because PBMs and insurers are watching this – and the last thing I want is to show them that pulling stuff like this is ok. It’s not, and we’re going to fight it. And win.

– Alicia

PS – if you only have the “a change is coming on July 1” letter

I’ve seen a lot of people try to appeal using these letters – this will not work. This letter is not a denial of coverage for Zepbound. All this tells you that they will deny it if coverage is requested after July 1, but you can’t appeal based on this.

If you’ve only gotten this letter and want to try to stay on Zepbound, you need to get denied first. That means:

1. Your provider needs to submit a new prior authorization request for Zepbound (form here)
   1. It’s best to do this with a LOMN attached (template here, Lilly has one also)
2. You wait until that prior authorization gets denied
3. Then you can appeal

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If you’re one of the many patients impacted by the forced switch from Zepbound to Wegovy, you’ve probably received a confusing series of letters and messages – some from CVS Caremark, some from your doctor, and maybe even some from your pharmacy. Understanding what each document means is key to getting back on the path to coverage.

This article breaks down the three critical documents you’ve likely received through the process. We’ll show you what they are, what they mean, and – most importantly – how to use them to get covered again.

👉 If you haven’t already, check out our full guide to fighting the Zepbound switch here.

Document 1: The Formulary Change Notice Letter

What it is:

A notification of an upcoming change to your coverage. This letter tells you that soon, a change to formulary or drug policy will remove Zepbound and prefer Wegovy. It lays out steps to prepare, such as when to file a new prior authorization (for most people, after July 1st) and how to switch your prescription.

Why you get it:

Health insurers and pharmacy benefit managers, like CVS Caremark, must provide 60 days’ advance notice to plan participants before any mid-year formulary change that removes a drug from coverage or limits its availability (e.g. adds step therapy, prior authorization, or tiering).

How to read it:

The truth? There’s not a lot in here. These letters often use vague language like “no longer be covered” and “you’ll need to pay the full cost”, but don’t provide specifics. That’s because, importantly, this is not a denial, which is required to provide you much more detail. 

Key takeaway:

This letter alone does not mean that your Zepbound prescription has been denied, or trigger your right to appeal. It’s a heads-up, not a final decision.

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Document 2: Your Doctor’s New Prior Authorization Form

What it is:

A prior authorization is a form your doctor submits ahead of prescribing something, so the insurer can sign off on your treatment before it gets prescribed. With the Caremark switch, even if you had a prior authorization (PA) approved for Zepbound, your doctor must submit a new one after July 1. This is the PA form they must submit, and we also recommend they draft a letter of medical necessity.

Why it’s necessary:

Because Caremark’s formulary changed, all existing PA approvals under the old formulary are essentially wiped out. Your provider needs to justify, again, that the treatment is medically necessary and follows standard guidelines. If this feels like a huge waste of time, providers agree: PA has been proven to delay care and harm patients, and it’s costly for providers to complete.

How to use it:

Ask your doctor if a new PA has been submitted. This is your official request for your insurance to cover Zepbound, and it needs to be on record after July 1 for the appeals process to work. For best results, have them include a letter of medical necessity (you’ll also want this ready for your appeal). A little appreciation goes a long way.

Key takeaway:

An official denial won’t come until a new PA is submitted. This form restarts the process.

Document 3: The Denial Letter (Now You Can Appeal)

What it is:

This is the official decision from your insurer rejecting the PA request for Zepbound. It typically arrives by mail or through your health plan portal.

Why you get it:

Insurers and PBMs (like CVS Caremark) are legally required to ensure you understand the reason for a coverage denial and have a meaningful opportunity to appeal. When denial language is vague, incomplete, or misleading, it undermines this legal purpose and obstructs fair access to care – and if that happens, we can help you fight it.

How to read it:

Look for the specific denial rationale and appeal instructions. You might see language like “the primary covered drug for your plan is Wegovy” or “another option for you is a tirzepatide product.” 

This language is misleading: You always have the right to request a formulary exception when no equivalent alternative exists. Zepbound is the only FDA-approved tirzepatide for obesity and sleep apnea, and has also been proven to be more effective, with fewer side effects, than Wegovy. Thus, it is the only tirzepatide product that should be covered by your plan.

What we think? This gives you a strong case to stay on Zepbound in your appeal.

Key takeaway:

This denial is what makes you eligible to file an appeal. If you haven’t gotten this yet, first make sure the PA has been submitted. If you appeal before you get this denial, it may be rejected or ignored – but don’t worry if this happens. You can resubmit.

Putting It All Together

A successful Zepbound appeal means getting the documents right:

1. The 60-day notice tells you this is coming, but isn’t a denial.

2. Your doctor’s new PA starts the process under the new rules.

3. Your denial letter gives you the right to appeal.

👉 If you’ve received your denial letter and are ready to appeal, Claimable can help you fight back in minutes. Get started today.

Need Help?

Still confused? You’re not alone. These documents weren’t designed for patients. That’s why Claimable exists – to help you translate legal jargon into action. Reach out at support@getclaimable.com.

When your insurance denies coverage for something your doctor says you need, it can feel like hitting a wall. The treatment is medically necessary. Your provider agrees. And somehow, your insurer still says “no.”

At that point, most people do the same thing: they call their doctor’s office and ask them to help. That makes sense – most patients haven’t had to appeal an insurance decision before, and assume that since the prescription came from their doctor, so should the appeal to cover it.

But here’s what most people don’t know: health insurance appeals aren’t just medical arguments. They’re regulatory, contractual, and strategic. They require paperwork, persistence, and the ability to challenge a policy – not just explain a diagnosis. 

Saying the quiet part out loud: your doctor’s appeal isn’t always enough. Sometimes, it’s not even the best place to start. That’s why if you want the best shot at getting coverage approved, you should appeal it yourself.

What’s the difference between my appeal and one that comes from my doctor?

When your insurer denies a medication, treatment, or service, there are two types of appeals that can be submitted:

• A provider appeal is when your doctor or their billing team contacts your insurer to argue that the treatment is medically necessary. These usually happen through the insurer’s internal system and often involve submitting clinical documentation.
• A patient appeal is when you, the person covered by the plan, formally challenge the denial. This taps into patient and consumer protections, and gives you access to additional tools, like independent reviews and mandated timelines and processes.

They may sound similar, but they vary. How are these types of appeals different?

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Now you can see some of the strengths that come from choosing to appeal yourself, as a patient – but it might still seem scary to take on. Apprehension about appeals isn’t an accident – insurers have spent years trying to make this seem hard, so people don’t do it. 

Common misconceptions about insurance appeals – and what they get wrong.

If you’ve never appealed an insurance denial before, you’re not alone (and you’re not behind). Most people don’t learn how this works until they have to.

This is often made harder by the assumptions people make about appeals. Here’s three of the most common misconceptions—and the truth about what actually works when you’re fighting a denial.

Misconception #1: “My doctor will take care of it.”

We hear this all the time. You get denied, and your first call is to your doctor to ask what to do. After all, they prescribed the treatment – surely it’s up to them to explain why you need it covered, right?

Why this doesn’t work:

Your doctor can support an appeal, but they’re not insurance policy experts – and more importantly, they’re not the one whose plan is in question here. Their top priority is to care for their patients, and they have limited options and resources to address the rising denial volume.

The reality:

You, the patient, hold the contract. The job of an appeal is to prove a denied treatment or service was contractually obligated to be paid for. This is equal parts a patient and consumer protection issue.

Misconception #2: “I don’t know how to do this — I’ll mess it up.”

It makes sense to feel this way – the healthcare system is overwhelming, and insurance is confusing on purpose. They want you to give up. That means that if you’ve never appealed before, it can feel like you’re not qualified to try.

Why this doesn’t work:

Assuming you’re not capable leads to inaction while you search for someone else to do it. Lawyers are expensive and don’t take many cases. Doctors don’t have the time, resources or rights to escalate appeals. And every time an unjust denial goes unchallenged, insurers are emboldened to deny more medically necessary care.

The reality:

Not long ago, it felt impossible to make this case on your own. Not anymore. With tools like Claimable, all you have to do is share your story and answer a few easy, guided questions. Then, we’ll pull all of the right laws, policies, and studies to make you the strongest appeal.

Misconception #3: “Its pointless — If they denied me, it must not be covered.”

This is what insurance companies want you to believe. That a denial is final, that you’re out of options, and that fighting back is too complicated or hopeless to be worth it.

Why this doesn’t work:

It causes people to give up on treatment they need, or to pay out-of-pocket for something their insurance might have covered – if only they had pushed back.

The reality:

Insurance companies deny coverage in error all the time – either due to mistakes or misconduct. Appealing is a built-in protection from a broken system. In fact, more than half of denials are overturned on appeal – and you have the power to take them on.

Why you should lead your own appeal

The best person to advocate for your care is you. Here’s why:

You hold the contract (and the legal rights that go with it)

Your doctor is there to care for you — but you’re the one who has a legal agreement with your insurance company. That gives you rights your doctor doesn’t have on their own, including state and federal protections.

When you appeal directly, you can:

• Trigger faster, legally mandated response times (like 72 hours for urgent cases)
• Escalate to external reviewers or regulatory agencies – including the ability to file complaints with your state’s insurance board
• Demand a full, fair review based on your policy’s language

You can move faster

When providers appeal, the paperwork often gets routed through internal insurer systems that are slow, opaque, and hard to track. Appeals can get stuck in “processing” or lost altogether.

When you appeal yourself, you’re in control. You don’t have to wait for office staff to call the insurer back or follow up on a fax. You set the pace – and you can hold your insurer accountable for timely responses.

You can make a stronger, more complete case.

Provider appeals are almost always focused only on clinical information. But winning an appeal often requires:

• Legal or regulatory arguments
• Citing FDA standards or policy precedent
• Personal impact statements about how the denial is affecting your life

Your doctor isn’t trained in insurance law. And they shouldn’t have to be. By appealing yourself — especially with help from a tool like Claimable — you can bring all these elements together into a comprehensive case that’s much harder to ignore.

You care the most – and in your appeal, that shows

Your doctor has hundreds of patients, dozens of responsibilities, and limited time. Appeals are just one more administrative burden in a broken system.

But for you, this appeal matters. It’s your treatment, your time, your health. That motivation — paired with the right tools — is what makes you the most effective person to lead the charge.

Why doctors don’t always win appeals (and that’s ok)

When you bring a denial to your doctor, they do what they can. A good provider is invested in your care, and they want to help get you the treatment they’ve prescribed. But the truth is: most provider-led appeals are brief, clinical, and limited in how far they can go. 

Why? Doctors have no power over the insurance company. They don’t hold an insurance contract (like you do). And the system is set up to make it all too easy for the insurer just to say no all over again.

Here’s how provider appeals typically go:

• First, they write a letter of medical necessity and send it over.
• Once insurance denies it again, your provider has a “peer-to-peer review” with a doctor who works for the insurance company. The reality? The job of the peer reviewer is to explain to your doctor why the insurer isn’t going to pay for it.
• And that might be it – they’ve reached the end of the road on this appeal.

That’s not their failure – it’s just a reflection of the system. Doctors aren’t trained or resourced to fight complex coverage decisions. That’s not what they went to med school for. They’re here to take care of you. The rest is up to you – and tools like Claimable.

How to work with your doctor – while staying in the drivers’ seat on your care

Appealing yourself doesn’t mean doing everything alone. Think of it like this: you’re the quarterback, and your provider is your key teammate.

When you get denied, here’s how to work with your doctor on your appeal.

1. Loop them in: Let their office know that your medication or service was denied, and that you plan to submit your own appeal. Most will be supportive — and sometimes relieved — that you’re taking the lead. Try this: 
2. “I’m planning to appeal my denial directly, since I can escalate it beyond internal review. Would you be willing to support the appeal with a letter or documentation showing this treatment is medically necessary?”
3. Ask for what they do best: Medical support. You don’t need them to write a legal brief – just a solid medical explanation. Request:
   • A Letter of Medical Necessity (try our LOMN template to make it easy!)
   • Diagnosis codes and chart notes\
   • Any history of treatments that didn’t work
4. Keep communication clear and focused. No need to forward your entire appeal draft. Instead:
   • Summarize what you’re submitting
   • Make 1–2 specific asks
   • Respect their time — they’ll appreciate it
5. Follow up and share your success: Let your provider know the outcome of the appeal. It helps close the loop and might even help future patients.

The easiest, most effective way to do your appeal

By now, we hope you see the value in taking charge of your appeal – and your care – directly. But researching all of the laws, policies, and . Luckily, you don’t need to be an insurance expert to write a winning appeal. That’s exactly what we built Claimable to do.

Here’s how it works:

• You answer a short set of questions about your medical and personal history
• You provide key documents, like your doctor’s letter of medical necessity
• We incorporate legal precedent, policy, and clinical standards
• We create a strong, customized appeal with the best arguments
• You approve – and we automatically sent it to your insurer and other key recipients

It’s that easy. In minutes – not days – you can build a case and fight back against your denial. And win.

The bottom line: You’re the best person to fight for your care

Your doctor is here to care for you. Your insurer is here to protect their business. And you? You’re the one who has the most to gain – or lose – from this decision.

Insurance companies count on confusion. On delays. On patients giving up. But you don’t have to play by those rules.

By appealing directly – and using every right the law gives you – you give yourself the best chance at getting the care you need. With your doctor on your side and Claimable in your corner, you’re not just filing an appeal. You’re creating a case that’s built to win.

You have the right. You have the tools. You’ve got this.

Start your appeal today →

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