How to appeal a Zepbound denial

The FDA approved Zepbound (tirzepatide) on November 8, 2023 for chronic weight management in adults with obesity, or adults who are overweight and have at least one weight-related condition.

On December 20, 2024, the FDA approved a second use: moderate to severe obstructive sleep apnea in adults with obesity. As of November 2026, the current prescribing information still lists those two uses.

Which use is written on the prescription matters. Medicare, for example, cannot cover drugs used for weight loss under Part D, but Medicare says Part D plans should cover GLP-1 drugs prescribed for moderate to severe sleep apnea.

The plan excludes weight-loss drugs. Many job-based plans do not cover them. In KFF's 2026 employer survey, 18 percent of firms with 200 or more workers covered GLP-1 drugs for weight loss, and 12 percent of the firms that did not cover them said they had stopped within the past year.

Prior-authorization criteria were not met. Plans that cover Zepbound tend to require approval first. A 2024 Peterson-KFF review of federal Marketplace plans found that every plan covering the weight-loss drugs required prior authorization, and most set quantity limits.

Each plan writes its own criteria. One large insurer's published Zepbound policy, effective September 2026, asks for a starting BMI of 30, or 27 with a weight-related condition, use alongside diet and behavior changes, and, at renewal, a loss of at least 5 percent of starting weight.

Zepbound is not on the drug list. A plan may cover a different GLP-1 drug and leave Zepbound off. That is a formulary decision, and it has its own exception process.

Start with the denial letter. For job-based plans, federal rules require the notice to state the specific reason and the specific plan provision behind the decision.

• Words like "excluded," "not a covered benefit" or "weight loss drugs are not covered" point to an exclusion.
• Words like "criteria not met," "prior authorization required" or "not medically necessary" point to a prior-authorization or medical-necessity denial. If the plan used written criteria, you can ask for a free copy.
• "Non-formulary" or "not on the drug list" means the plan covers drugs but not this one.

Then check three documents. The Summary of Benefits and Coverage has a section titled "Services Your Plan Generally Does NOT Cover". The formulary, or drug list, shows whether Zepbound is listed and with what limits; HealthCare.gov suggests checking your insurer's website. The plan document, called the Summary Plan Description in job-based plans, has the full exclusion wording. One insurer's policy says the plan document always wins when it conflicts with the insurer's clinical rules.

If the plan excludes weight-loss drugs and Zepbound was prescribed for weight loss, an appeal arguing medical need has no plan rule to point to. HealthCare.gov lists the denials that can go to external review: ones involving medical judgment, experimental treatment or cancelled coverage. A plain exclusion is not on that list. See appealing an exclusion for more.

Appeal when the denial says criteria were not met, or when Zepbound was prescribed for sleep apnea. Ask your doctor's office to make sure the prescription, the prior-authorization request and the appeal all name the same diagnosis.

For sleep apnea, one insurer's criteria ask for a sleep study showing an apnea-hypopnea index of 15 or more events per hour, a starting BMI of at least 30, and no central sleep apnea. Records to gather:

• The sleep study report with its date and AHI.
• Your starting weight, height and BMI, dated.
• Diagnoses for weight-related conditions such as high blood pressure.
• A note that Zepbound will be used with diet and activity changes.
• For a renewal, weights showing your percent change since you started.

File the internal appeal within 180 days of the denial. If your plan's exclusion is written for drugs "used for weight loss," ask the plan in writing whether it applies when Zepbound is prescribed for sleep apnea. For missing paperwork, see prior-authorization denials.

Individual and small-group plans must cover essential health benefits, and those plans must run a drug exception process under 45 CFR 156.122(c). A standard request must be decided within 72 hours. An expedited request, when your health is at serious risk or you are mid-treatment, must be decided within 24 hours. If the plan says no, you can ask for review by an independent organization.

For an exception, your doctor generally confirms that covered drugs have not worked, will not work as well, or are likely to cause harm.

Your employer chooses much of what a job-based plan covers. Seventy-one percent of covered workers are in self-funded plans, where the employer pays the claims. Ask your HR or benefits team whether the plan covers Zepbound for weight loss or sleep apnea, and whether it requires a dietitian or lifestyle program. See employer plan appeals.

Lilly runs LillyDirect for help with prescriptions and savings options.

Federal law keeps out of Part D most drug uses that Medicaid may exclude, and that list includes agents used for weight loss. For sleep apnea, go through your Part D plan. An exception request needs a statement from your prescriber, and the plan must decide within 72 hours, or 24 hours if expedited. You have 65 days to appeal. See Part D appeals.

For weight loss, Medicare runs the Medicare GLP-1 Bridge from July 1, 2026, through December 31, 2027, outside the Part D benefit. It covers the Zepbound KwikPen only, not vials or single-dose pens. People with type 2 diabetes, sleep apnea or fatty liver disease go through their Part D plan instead. If a Bridge request is denied, your prescriber can resubmit it for re-review.

State Medicaid coverage for obesity is optional; 13 states covered GLP-1s for obesity as of January 2026. See Medicaid appeals.