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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