How to appeal a Wegovy denial

What Wegovy is approved for

Why plans deny Wegovy

Exclusion or prior-authorization denial: how to tell

Appeals for heart disease or MASH

Formulary exceptions and your employer

Medicare and Medicaid

Questions people ask

Sources

1. U.S. Food and Drug Administration: Drugs@FDA: FDA-Approved Drugs (Wegovy, NDA 215256)06/04/2021 ORIG-1 Approval
2. U.S. Food and Drug Administration: WEGOVY (semaglutide) injection and tablets prescribing information, June 2026 (Drugs@FDA)with moderate to advanced liver fibrosis (consistent with stages F2 to F3 fibrosis) in adults
3. U.S. Food and Drug Administration: FDA Approves First Treatment to Reduce Risk of Serious Heart Problems Specifically in Adults with Obesity or OverweightToday, the U.S. Food and Drug Administration approved a new indication for use for Wegovy (semaglutide) injection to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight.
4. U.S. Food and Drug Administration: NDA 215256/S-024 Accelerated Approval letter for Wegovy (August 15, 2025)provides for the addition of an indication for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH)
5. U.S. Food and Drug Administration: Drugs@FDA: FDA-Approved Drugs (Wegovy tablets, NDA 218316)12/22/2025 ORIG-1 Approval Type 3 - New Dosage Form
6. KFF: 2026 Employer Health Benefits SurveyThe overall percentage of firms with 200 or more workers that cover GLP-1 agonists for weight loss (18%) is similar to the percentage last year (19%) and two years ago
7. Peterson-KFF Health System Tracker: Insurer strategies to control costs associated with weight loss drugsAll plans covering the drugs approved for weight loss require prior authorization. Similarly, quantity limits are imposed in most plans among those including these drugs on formulary.
8. eCFR (Office of the Federal Register): 29 CFR 2560.503-1 -- Claims procedureReference to the specific plan provisions on which the determination is based
9. Centers for Medicare & Medicaid Services: Summary of Benefits and Coverage template (accessible format)Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
10. HealthCare.gov: Summary of Benefits and CoverageYou have the right to an easy-to-understand summary about a health plan’s benefits and coverage.
11. HealthCare.gov: Getting prescription medicationsVisit your insurer’s website to review a list of prescriptions your plan covers
12. U.S. Department of Labor: Filing a Claim for Your Health BenefitsWhen you first enroll in your employer's plan, you will receive a document called the Summary Plan Description (SPD).
13. HealthCare.gov: External ReviewAny denial that involves medical judgment where you or your provider may disagree with the health insurance plan
14. HealthCare.gov: Internal appealsYou must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
15. eCFR (Office of the Federal Register): 45 CFR 156.122 -- Prescription drug benefitsA health plan must make its determination on a standard exception and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following receipt of the request.
16. HealthCare.gov: Self-insured plan - Glossarythe employer itself collects premiums from enrollees and takes on the responsibility of paying employees’ and dependents’ medical claims
17. Novo Nordisk: Support Starts Here for Patients Taking Novo Medicines | Novocare®offers the guidance, savings, and support you need to keep moving forward
18. Legal Information Institute, Cornell Law School: 42 U.S. Code § 1395w-102 - Prescription drug benefitswhich may be excluded from coverage or otherwise restricted under section 1396r–8(d)(2) of this title
19. Legal Information Institute, Cornell Law School: 42 U.S. Code § 1396r-8 - Payment for covered outpatient drugs(A) Agents when used for anorexia, weight loss, or weight gain.
20. KFF: A New Use for Wegovy Opens the Door to Medicare Coverage for Millions of People with Obesityissued a memo indicating that Medicare Part D plans can add Wegovy to their formularies now that it has a medically-accepted indication that is not specifically excluded from Medicare coverage
21. Medicare.gov: Weight loss drugsYou aren't eligible for the Medicare GLP-1 Bridge, because your Medicare drug plan should cover GLP-1 medications to treat these conditions.
22. Medicare.gov: Appeals in a Medicare drug planIf you're asking for an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.
23. Centers for Medicare & Medicaid Services: Medicare GLP-1 BridgeThe Medicare GLP-1 Bridge is a short-term demonstration run by CMS that will provide eligible Medicare Part D beneficiaries with access to certain GLP-1 drugs between July 1, 2026, and December 31, 2027.
24. Centers for Medicare & Medicaid Services: Status Update on the BRIDGE Demo and BALANCE Model in Part D for CY2027 (HPMS memo, April 21, 2026)CMS will delay implementation of the Medicare Part D portion of Better Approaches to Lifestyle and Nutrition for Comprehensive Health (BALANCE) Model for Calendar Year (CY) 2027 pending further evaluation and data collection.
25. KFF: Medicaid Coverage of and Spending on GLP-1sMedicaid coverage of GLP-1 drugs for obesity treatment is optional for states, while coverage for other indications (diabetes, cardiovascular disease, and sleep apnea) is required.
26. Centers for Medicare & Medicaid Services: BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) ModelState Medicaid agencies can join the model beginning in May 2026 through January 1, 2027.