How to get GLP-1s with insurance

To get a GLP-1 medication with insurance, you’ll want to review your plan’s list of covered medications and have your healthcare provider submit prior authorization paperwork on your behalf. The process can require some back and forth with your insurance company. 

That's why we wrote this article: to make the insurance process easier to navigate. If you're ready to start treatment with GLP-1 medication such as Wegovy (semaglutide) or Zepbound (tirzepatide) for weight loss, read on.

Getting your insurance plan to cover your GLP-1 sometimes requires a bit more legwork than other medications, but the process essentially boils down to four steps:

1. Review your plan’s list of covered medications, aka formulary (or use Ro’s GLP-1 Insurance Checker) 

2. Get a prescription from a licensed healthcare provider

3. Submit a prior authorization request

4. Get approved, appeal, or request an exception

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1. Review your plan's formulary and coverage criteria

Your plan’s formulary is a list of all the medications that are covered by your plan. You can usually find it on your insurance provider’s website or patient portal. 

If the formulary lists a GLP-1, that means it's covered under your specific plan, though you may need to meet certain coverage requirements. If a GLP-1 isn't listed, that means it isn't covered by your plan. However, know that insurance plans can change their coverage of GLP-1s at any time, so it's worth calling your insurance plan directly to confirm the medication is still covered.

If a medication is covered, the formulary will tell you its:

• Cost tier. GLP-1s typically have higher co-pays. If you have a deductible on your commercial insurance plan, you may have to pay more for the medication until you meet it. After that, your plan’s usual copay or coinsurance may apply. 

• Covered conditions. Generally, insurance plans are more likely to cover a medication for its FDA-approved condition. So, your insurance plan may cover Wegovy, Zepbound, or Saxenda (liraglutide) for chronic weight management — but not Ozempic (semaglutide) or Mounjaro (tirzepatide), which are approved for diabetes and not specifically for weight loss.

• Coverage requirements. Some insurance plans require step therapy and/or prior authorization before they’ll cover a GLP-1. We’ll review these in the next step.

Not sure if your plan covers your GLP-1? Depending on the medication, you can find out using Ro’s free GLP-1 Insurance Coverage Checker.

2. Get a prescription from a healthcare provider 

Now that you know which GLP-1 medications are covered by your plan, you’ll need to meet with a healthcare provider to get a prescription (that is, of course, as long as the provider thinks GLP-1 treatment is a fit). 

You can do so in person by meeting with a provider, such as your primary care physician, or online via a telehealth platform like Ro. 

If you opt for the virtual route with Ro’s weight loss program, your first step is to answer a few questions about your health history and weight loss goals. From there, a licensed healthcare provider affiliated with Ro will review your responses and determine whether you’re a good fit for GLP-1 treatment within a few days. Sometimes, they may order a metabolic lab test (included in your membership cost) to better understand your hormone and metabolic health or to support insurance coverage.

If eligible, your Ro-affiliated provider will then write you a prescription for the specific GLP-1 medication. And as a Ro Body member, you can tap Ro’s insurance concierge for help with figuring out and securing insurance coverage. 

When you meet with a provider in person, you will likely be asked similar questions to those in Ro’s online visit. 

During your appointment, your provider will inquire about your personal and family medical history. Some pre-existing health conditions make some GLP-1 medications unsafe or require extra caution. For example, several GLP-1–based medications should not be used if you or a family member has had medullary thyroid carcinoma (MTC) or if you have multiple endocrine neoplasia syndrome type 2 (MEN2).By sharing your full medical history with your provider (in person or virtually, for that matter), you can help them determine which medication is safe for you. 

Be sure to tell them about any medications you are taking, including prescription medications, over-the-counter (OTC) supplements, and vitamins. GLP-1 medications work by delaying gastric emptying, which can affect your body’s absorption of oral medications.

Also, share your experience with losing weight through other methods. Understanding how your body has responded to different eating plans, exercise, or other medications can help your provider determine whether a GLP-1 such as Wegovy or Zepbound is a good choice for you or if another weight loss medication or intervention could be more effective.

"This [information] will help our providers advocate for them and demonstrate to the insurance provider that a patient has tried many different types of medications, diets, and exercise plans and they have not worked," says Raoul Manalac, MD, a board-certified internal medicine physician and Senior Director of Obesity Medicine at Ro.

3. Submit prior authorization (PA)

Most insurance plans, including Medicare, require prior authorization (PA) before they will cover a GLP-1 medication. PA is paperwork your healthcare provider submits on your behalf stating that you meet your insurance plan’s coverage criteria for a GLP-1. When taking a GLP-1 for weight loss, this may include:

• Your body weight/BMI. GLP-1s are approved for weight loss in people with obesity or with overweight and a weight-related medical condition, such as high cholesterol or type 2 diabetes. You can check where you fall using a body mass index (BMI) calculator, though your healthcare provider will weigh other health factors beyond this number alone.

• Step therapy. Some plans require you to try a less expensive medication or an eating and exercise program first before they'll cover a GLP-1 for weight loss. While the specific timeline can vary by plan, generally, some may require documentation that you participated in a lifestyle program or tried another treatment first.

• A commitment to making lifestyle changes. Specifically, your plan may want confirmation that your treatment plan includes not only taking the GLP-1 medication, but taking it in combination with the recommended lifestyle changes (i.e. a reduced-calorie eating plan and increased physical activity).

Once your healthcare provider submits the form, it can take up to 15 days for your insurance company to review it and issue a response. Medicare Part D generally requires a decision on a standard drug coverage request within 72 hours. Prior authorization decisions through the Medicare GLP-1 Bridge are also generally communicated within 72 hours.

Ro Body members can access Ro’s insurance concierge for help navigating all things insurance coverage. If a Ro-affiliated provider writes you an Rx, the concierge will coordinate with your insurance to help get medication costs covered. 

In other words, they do all of the heavy lifting: communicating directly with your insurance provider, submitting paperwork for PA, and even exploring cost-saving options — all on your behalf and at no additional charge. The process takes 1–3 weeks, and when coverage is determined, they’ll send your script to your preferred pharmacy to be filled.

See if you qualify

4. Respond to your insurance company's decision

If your insurance plan approves your prior authorization request, you’re good to go!

If your plan didn’t approve your request, don’t lose hope just yet. Read carefully to understand the reason why (they have to give you one). It’s possible that the paperwork was incomplete, and they’re simply asking for more information. In this scenario, your healthcare provider can resubmit the prior authorization with the requested information.

If they denied coverage outright, you can appeal their denial or request an exception. In this scenario, your healthcare provider may need to submit a letter of medical necessity explaining why it is medically necessary and why covered alternatives may not be appropriate for you.

If your insurance plan still denies coverage, you may need to go back to the drawing board with your healthcare provider. Talk to them about your other GLP-1 treatment options, if there are any that are covered by your plan. 

If your plan only covers traditional weight loss pills, you can also ask your provider if they may be a good alternative. While they’re typically less effective than GLP-1s for weight loss, they can be less expensive out-of-pocket.  

If you are denied insurance coverage for GLP-1s, there are still ways you can save on the medication.

Just because insurance may not cover your treatment doesn't mean the road ends there — you can still get your Rx (if appropriate) at a fraction of the list price on Ro.

If you haven't already, you'll first need to complete an online visit, which will then be reviewed by a Ro-affiliated healthcare provider. If your provider determines a GLP-1 medication is a fit, they'll write you a prescription, and you can simply opt to pay cash. Depending on the medication prescribed, your medication may cost just $149 per month.

Here are the cash-pay prices for GLP-1s on Ro (if prescribed)*:

• Wegovy pill: $149–$299 per month, depending on the dose

• Wegovy pen: $199–$399 per month, depending on the dose 

• Zepbound KwikPen: $299-$449 per month, depending on the dose

• Foundayo:  $149–$299 per month, depending on the dose 

Manufacturer savings cards are also worth a look — though for GLP-1s already available through cash-pay on Ro, like Wegovy, Zepbound, and Foundayo, these cards typically bring the uninsured price to about the same range you'd already get on Ro. They're more likely to make a real difference for medications not currently available for cash-pay on Ro, like Mounjaro and Ozempic, or if you have some insurance coverage that just doesn't include your GLP-1 — in that case, a card can sometimes bring your cost down to as low as $25 per month. The one exception is Medicare, Medicaid, and other government-funded insurance plans, which aren't eligible for these savings offers.

Here's a quick look at the price of GLP-1s with manufacturer savings cards:

• Foundayo: As low as $25 per month (with coverage); $149–$299 per month (without coverage)

• Mounjaro: As low as $25 per month (with coverage); as low as $499 per month (without coverage)

• Ozempic pill: As low as $25 per month (with coverage); $149–$299 per month (without coverage)

• Ozempic pen: As low as $25 per month (with coverage); $199–$499 per month (without coverage)

• Wegovy pill: As low as $25 per month (with coverage); $149–$299 per month (without coverage)

• Wegovy pen: As low as $25 per month (with coverage); $199–$399 per month (without coverage)

• Zepbound: As low as $25 per month (with coverage); $299–$499 per month (without coverage)

The savings card program for Saxenda has been discontinued. 

Next, price-shop local pharmacies. Prices can vary from pharmacy to pharmacy, and some may have promotions or coupons that lower the price of the medication. Also, check online pharmacies, which may include free shipping to your home.

If you can afford it, sometimes purchasing a two- or three-month medication refill can be more cost-effective over the long run than a one-month refill.

Finally, if you choose to fill at your pharmacy, you may still be able to save using a pharmacy discount card. These are available for free from websites like GoodRx, SingleCare, and OptumPerks. You just need to select your GLP-1, dose, and preferred pharmacy to download or print your coupon.

*Pricing may reflect limited-time and/or manufacturer offers. Terms and conditions may apply for certain doses; see more here.

See if you qualify

Insurance coverage isn't always guaranteed for GLP-1s. Plans can choose which medications to include in their formularies.

• You can find out if your insurance covers GLP-1s by reviewing your formulary online or calling the number on the back of your insurance card.

• If you have an insurance plan that does cover a GLP-1, your healthcare provider will likely need to submit prior authorization on your behalf.

• If your insurance plan denies coverage, you can work with your healthcare provider to appeal their decision.

• Other ways to save on GLP-1s include manufacturer savings offers, self-pay options, and pharmacy coupons.