Your doctor prescribed a GLP-1. Your Medicare Part D plan says it won’t pay. Now what?

“Don’t assume you’re out of luck,” said Gretchen Dueñas-Tanbonliong, MS, MPH, RDN, MCHES, Associate Director of Health and Wellness at NCOA. “There are a variety of reasons this may have happened.”

Medicare does cover GLP-1s, but the rules are complex and open for misunderstanding and errors. That’s why Dueñas-Tanbonliong recommends following up with your health care provider. “In some cases—not all, but some—there’s a pathway to getting your medication covered,” she said.

If Medicare denied your Wegovy, Zepbound, or other GLP-1, here are the specific steps you can take. 

What Can I Do If Medicare Denied My GLP-1?

First, know the decision may not be final. Whether or not it is depends on:

• What GLP-1 your doctor prescribed
• Who your Medicare Part D plan sponsor is
• Why your plan doesn’t cover it

Step 1: Find out why your GLP-1 isn’t covered

You’re at the pharmacy counter, ready to pick up your medication, when you get the bad news: It’s going to cost hundreds of dollars. And you’re on the hook for it.

There are several reasons why your Medicare Part D plan sponsor may have denied your prescription. The most likely one(s) include:

• Formulary restriction
Each plan has its own unique list of drugs it will pay for. Your specific GLP-1 may not be on it.

• Prior authorization rule
Your plan may require you to get advance permission or approval before it will pay for your GLP-1.

• Step therapy requirement
Many plans manage their GLP-1 costs by requiring you to try a less expensive option first.

• Non-covered indication
Medicare will only pay for GLP1-s approved by the FDA for specific health conditions. If your doctor prescribed yours for a different reason, it’s likely not covered.

• Unfavorable coverage determination
Your or your prescribing provider may have asked for an exception for a non-covered GLP-1 and your plan declined to grant it (more on this a little further down).

Step 2: Check your Medicare plan’s drug list

Each Part D (and Medicare Advantage plan with Part D) sponsor sets its own formulary. If the GLP-1 your doctor prescribed isn’t on it, your plan won’t pay.

There are several reasons why this may be the case, including:

• Your plan’s formulary doesn’t include GLP-1s at all
• Your plan’s formulary does include GLP-1s, but only will pay after you try a less expensive option first (this is called a “tiered” formulary or “step therapy”)
• Your plan’s formulary includes GLP-1s but not the specific one your doctor prescribed

Further, formularies can change year to year. Just because your plan covered a GLP-1 last year doesn’t guarantee it will next year. According to Dueñas-Tanbonliong, this is a common and easily-overlooked circumstance that can lead to unexpected denials.

➡️ How-to: Check your plan formulary

1. Visit Medicare.gov (or your specific plan’s website) and log into your account

2. Locate your Summary of Benefits and Coverage for a link or

3. Type “formulary” or “drug list” into the search bar

Alternately, you can ask your local pharmacist to run your GLP-1 through their computer system or call the customer service number on the back of your prescription drug ID card.

Sometimes, a similar medication may be available. For example, if Medicare denied your Wegovy because it’s not on your plan’s formulary, there may be an alternative that is.

Your health care provider can help you understand whether it’s appropriate and safe for you to try one of these instead.

Step 3: Talk with your doctor

Your health care provider is also your health care partner. If Medicare denied your Wegovy, Zepbound, or other GLP-1 prescription, you can work together to find out why and whether there’s a solution.

Step 4: Ask for a coverage determination or exception

There are many valid and critical health reasons why doctors prescribe GLP-1s. If your Part D plan sponsor doesn’t cover yours—or doesn’t include an equally effective alternative on its formulary—you have the right to ask them to change it.

What is a coverage determination?
A coverage determination is a blanket term describing a plan’s decisions about what prescription drugs it pays for and under what circumstances. If you (and/or your doctor) disagree with these decisions, you can request a review and ruling.

What is an exception?
An exception is a specific type of coverage determination and usually the most typical. You can ask for an exception to your plan’s tiering, in order to access your GLP-1 at a lower cost; or to its formulary, in order to access a non-covered GLP-1.

Step 5: File an appeal

If you or your provider requested a coverage redetermination or exception—and Medicare denied it—you have the right to appeal their decision.

“It’s important that you start this process as soon as you can,” Dueñas-Tanbonliong emphasized. That’s because you only have about 60 days from the date listed on your denial letter to file.

There are five steps to follow:

1. Appeal directly with your plan;
2. If unsuccessful, appeal with the independent review entity (IRE);
3. If unsuccessful, appeal with the Office of Medicare Hearings and Appeals (OMHA);
4. If unsuccessful, appeal to the Council; and
5. If unsuccessful, appeal with the Federal District Court

Each step involves different deadlines, documentation, and processes. To learn more, see our article on appealing a Part D drug coverage denial.

What about the Medicare GLP-1 Bridge?

Medicare Part D does not cover any medications for weight loss. Why? Because Medicare rules prohibit it.

That’s where the Medicare GLP-1 Bridge Program comes in. The program does what its name suggests: it bridges the gap between GLP-1s expressly prescribed for weight loss, and Part D’s inability to cover them.

The Medicare GLP-1 Bridge is not a drug plan, and your Plan D sponsor doesn’t administer it. It’s a separate, pilot program offered by the Centers for Medicare & Medicaid Services that’s currently set to expire on December 31, 2027.

Ask your health care provider if you think you may be eligible for this program.

Where can I get help understanding my Medicare Part D plan?

Medicare rules can be complicated and hard to sort out. If you need help understanding your prescription drug plan and coverage, your State Health Insurance Assistance Program is ready to step in.

Here, you’ll find certified counselors with specific expertise in Medicare plans and policies. These counselors offer their understanding and unbiased advice at no cost to you. Medicare enrollees, their families members, and caregivers can participate.

What to bring when you meet with a SHIP counselor

Once you find your local SHIP program and set up an initial meeting, it’s time to prepare. Before meeting with your counselor about Part D coverage for your GLP-1, gather the following:

✅ Your Medicare card

✅ Your Part D / Medicare Advantage plan information

✅ Your GLP-1 prescription (including brand name and dosage)

✅ Your denial letter

✅ Your health care provider name and other details

✅ Any other relevant medical documentation

The bottom line

If your healthcare provider prescribed Wegovy or Zepbound and your Medicare Part D plan denied it, don’t panic. There are a number of reasons why it may have happened and several clear steps you can take. Work with your doctor to identify an appropriate alternative and find out whether it’s on your plan’s formulary. If one doesn’t exist or the alternative also isn’t covered, you have the right to request an exception and—if unsuccessful—file an appeal. If your doctor prescribed a GLP-1 specifically for weight loss, ask about the Medicare GLP-1 Bridge Program and whether you’re eligible.