There are two separate hurdles. The first is the FDA label, which is a fixed rule about BMI and weight-related conditions. The second is your plan's coverage criteria, which are stricter and vary. This page handles both, in that order.
The label is the floor. Almost every plan that covers these drugs at all sits a prior authorisation on top, and the criteria are set by your employer or insurer rather than by the manufacturer. What they commonly ask for:
A documented weight history, not just today's weight. Plans often want to see the BMI threshold met on a dated clinical record, sometimes more than one, sometimes going back six or twelve months.
Evidence you tried something else first. This is the requirement that catches most people. It can mean a documented three to six months of a supervised diet and exercise programme, and self-reported attempts usually do not count. If you have done rounds with a dietitian, a hospital programme, or a previous weight medication, get those records.
The weight-related condition spelled out in the chart. If your qualifying condition is sleep apnea, a plan generally wants the sleep study, not a mention. If it is cardiovascular disease, it wants the diagnosis coded.
Re-authorisation. Many plans approve six months at a time and require evidence of a minimum loss, often around 5% of starting weight, to renew. Worth knowing on day one, because it makes the early weigh-ins matter administratively as well as personally.
A first denial is routine and is frequently procedural rather than a judgement about you. In order of what tends to work:
Find out the actual reason. Ask for the denial in writing with the specific criterion that was not met. Roughly half the time it is a missing document rather than a disagreement.
Ask the prescriber's office for a peer-to-peer review. Your prescriber talks directly to the plan's reviewing physician. It costs you nothing and it is the highest-yield step.
File the formal appeal, then the external review. Plans are required to give you an appeals path and, in most cases, an independent external review after internal appeals are exhausted. Deadlines are short, so start the day the denial arrives.
Ask about a formulary exception if the plan covers one GLP-1 but not the one you were prescribed, and about whether switching to the covered one is clinically reasonable. Often it is, and it is faster than fighting.
If none of it lands, self-pay channels exist and are cheaper than the list price. The cost calculator works out what a year actually runs on each channel, and which drug to ask for covers how coverage should shape the choice.
Weight history with dates. Blood pressure, lipid panel and A1c if you have them. A sleep study if one exists. A written list of what you have already tried, with rough dates and duration. Your insurance card and, ideally, the formulary answer from calling the number on the back of it.
Not on a prescriber yet: the telehealth page lists licensed US platforms prescribing the brand-name versions, and several of them handle the prior-authorisation paperwork as part of the service, which is worth more than it sounds.
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