The 2025 GLP-1 insurance landscape is defined by one word: contraction. Employers are removing coverage, Medicaid programs are retreating, and commercial insurers are erecting increasingly complex prior authorization barriers. But access pathways still exist—if you know where to look.
This guide covers the current coverage reality across all payer types, proven strategies for prior authorization success, and the new cash-pay options that may be cheaper than using insurance.
Medicare: The Statutory Wall (With Cracks)
The Medicare Modernization Act of 2003 explicitly excludes drugs used for weight loss from Part D coverage. This means Wegovy or Zepbound prescribed for obesity is not covered for the ~68 million Medicare beneficiaries.
A proposed 2026 pilot would expand Medicare coverage for obesity drugs with tiered eligibility:
- BMI ≥27 with prediabetes or CVD
- BMI ≥30 with uncontrolled hypertension, advanced kidney disease, or heart failure
- BMI ≥35 regardless of comorbidities
Proposed pricing: ~$245/month government cost, $50/month beneficiary copay. Not yet implemented—monitor for updates.
Medicaid: State-by-State Reality
Medicaid coverage for weight loss medications is optional—states choose whether to include them. As of late 2024, approximately 13 states maintained some coverage, but several are retreating due to budget pressure.
| State | Status | Notes |
|---|---|---|
| California | Ending | Weight loss coverage ends Jan 1, 2026. Diabetes/CVD coverage continues. |
| North Carolina | Terminated | Ended Oct 1, 2025 for obesity. Diabetes still covered. |
| New Hampshire | Ending | Weight loss coverage ends Jan 1, 2026. |
| Pennsylvania | Covered | Broad coverage. High spending ($298M reported). |
| Michigan | Covered | Comprehensive coverage for obesity agents. |
| Minnesota | Covered | Wegovy listed as preferred. |
| Wisconsin | Restricted | Step therapy required—must fail benzphetamine first. |
| Massachusetts | Restricted | Moved Wegovy to non-preferred; favoring Zepbound. |
Commercial Insurance: The Great Tightening
2025 is the year employers aggressively redesigned benefits to control GLP-1 costs—now the single largest driver of pharmacy spend increases.
BCBS Michigan: Ended weight loss coverage for fully insured plans Jan 2025.
BCBS Massachusetts: Limits GLP-1s to Type 2 Diabetes diagnoses only—no obesity coverage without employer "rider."
Independence Blue Cross (PA): Eliminating weight loss coverage for fully insured groups in 2025.
Florida Blue: Strict exclusion for weight loss. Coverage only for T2DM with metformin step therapy.
Kaiser Permanente: Removing GLP-1 weight loss coverage from "base" plans for BMI <40 in 2025.
Aetna: Some plans require BMI ≥35 (higher than FDA label of 30). 6-month behavioral modification prerequisite.
Prior Authorization: The Perfect Documentation Packet
PA success in 2025 requires forensic-level documentation. Insurers have moved beyond checkboxes to requiring comprehensive clinical narratives.
- BMI with date: Many plans now require BMI ≥32 or ≥35 (above FDA label)
- Specific ICD-10 codes: E66.01 (morbid obesity) + comorbidity codes (I10, E78.5, G47.33, R73.03)
- 6-month lifestyle documentation: Weight Watchers dates, gym receipts, dietitian notes, monthly weigh-ins showing <5% loss
- Failed previous attempts: Document contraindications to step therapy drugs (Phentermine, Contrave, Qsymia)
- Lab values: A1c, lipid panel, liver enzymes if relevant to comorbidities
ICD-10 Coding That Works
Use: E66.01 (Morbid obesity due to excess calories) + Z68.xx (BMI code) + at least one comorbidity:
• I10 (Hypertension)
• E78.5 (Hyperlipidemia)
• G47.33 (Obstructive sleep apnea) — especially valuable for Zepbound
• R73.03 (Prediabetes)
• I25.10 (ASHD) — critical for Medicare/Wegovy CVD indication
Common Denial Reasons & Rebuttals
| Denial Reason | Rebuttal Strategy |
|---|---|
| Plan Exclusion | Don't appeal for weight loss. If patient has CVD, appeal using cardiovascular indication (I25.10) citing FDA approval and CMS guidance. |
| Not Medically Necessary | Submit Letter of Medical Necessity focusing on metabolic syndrome markers (pre-diabetes, elevated CRP, fatty liver) that pose imminent risk. |
| Step Therapy Failure | Document contraindications: "Uncontrolled hypertension (contraindication for Phentermine)," "Seizure history (contraindication for Contrave)," "Childbearing age (risk for Qsymia)." |
| Missing Lifestyle Info | Aggregate data from health apps (MyFitnessPal, Apple Health), gym receipts, or dietitian attestations to reconstruct 6-month history. |
The Appeal Process
Internal Appeal Success Rate: 40-60% if denial was technical (missing labs, insufficient documentation). If denial is "Plan Exclusion," internal appeals rarely work.
Peer-to-Peer Review: Most effective tool. Physician calls insurer's medical director. Strategy: pivot from "weight loss" to "risk reduction"—cite SELECT trial (20% MACE reduction) and argue denial increases insurer's future stroke/MI liability.
External Review: If internal appeals exhausted, request Independent Review Organization (IRO) review. Success rate ~27-40%, but IROs follow clinical guidelines (ADA, AHA) over restrictive plan policies. Decisions are binding on insurer.
Cost Assistance Programs
With insurance increasingly restrictive, manufacturer programs have become critical—and some now rival compounding pharmacy prices.
Manufacturer Savings Cards (Insured Patients)
Novo Nordisk (Wegovy): Covers up to $225/month in copay costs. Potential $0 copay with commercial insurance.
Eli Lilly (Zepbound): Reduces copay to as low as $25/month (annual cap ~$1,800).
Important: Savings cards don't work with Medicare, Medicaid, or government plans. Commercial insurance only.
HSA/FSA Eligibility
Required: Letter of Medical Necessity (LMN) stating: "This medication is medically necessary to treat the specific diagnosis of Obesity (ICD-10 E66.01) and [comorbidity]. It is not for general health or cosmetic purposes."
Submit LMN to your HSA/FSA administrator (HealthEquity, Navia, etc.) to unlock reimbursement.
Before You Start: Verification Protocol
- Step 1: Log into your PBM portal (Caremark, Express Scripts, OptumRx)—not the medical insurance site
- Step 2: Use "Price a Medication" tool. Enter Wegovy and Zepbound. Results: Price shown = on formulary. "Not Covered" = blocked. "PA Required" = gated but possible.
- Step 3: Call and ask: "Does my plan have a weight loss rider? Is there a specific exclusions list for anti-obesity medications?"
The Math: Insurance vs. Cash Pay
With manufacturer direct programs offering brand-name drugs for $350-550/month, the calculus is changing:
- High-deductible plan ($3,000+): Cash pay may be cheaper than meeting deductible
- Plan with PA hassle but eventual coverage: Worth the fight—long-term savings
- Plan exclusion for weight loss: Cash pay or compounded are only options
- Gap narrowing: Brand cash pay ($350) vs. compounded ($200-300) = $50-150 difference for FDA-approved quality assurance
- CMS. Medicare Part D GLP-1 Coverage Guidance. 2024.
- KFF. "Medicaid Coverage of and Spending on GLP-1s." 2025.
- Becker's Hospital Review. "The GLP-1 Dilemma Persists Into 2025."
- UnitedHealthcare. "Total Weight Support Program." 2025.
- BCBS Michigan. Coverage Policy Update. January 2025.
- Aetna Clinical Policy Bulletins 0450/0598.
- Cigna/Express Scripts. EncircleRx Program Terms.
- NC Medicaid. "Coverage Change for GLP-1 Weight Management." October 2025.
- White House. "TrumpRx Most-Favored-Nation Pricing Fact Sheet." November 2025.
- NovoCare. Wegovy Savings Programs. 2025.
- LillyDirect. Zepbound Cash-Pay Options. 2025.
- IRS Code 213(d). Medical Expense Eligibility.
- Counterforce Health. "Fighting the 'Medically Necessary' Denial for GLP-1s."
- Healthcare.gov. External Review Process.