How do you read your plan’s drug list for Wegovy, Zepbound or Ozempic, and ask for an exception?

What is a drug list, and where do you find yours?

Your plan’s drug list (formulary) names every medicine it covers, the cost level (tier) of each one and any rules attached to it.¹

Each plan writes its own list and chooses which drugs to include.¹ Medicare says plans can change their list during the year, and must tell you about changes that affect drugs you take.¹

Many plans treat GLP‑1s differently by use. In February 2026, one regional insurer, Premera, described two separate paths:²

• Type 2 diabetes: GLP‑1s approved for diabetes are covered across all its plans, with a documented diagnosis and medical-necessity criteria.
• Weight management: covered only when the employer has chosen that benefit. Wegovy and Zepbound then need prior authorization.

That is one insurer’s published policy, not a rule for every plan. Look for your own list on your plan’s website or member portal, or call the number on your card. On Medicare, see how Medicare covers GLP‑1s.

What do the tiers on a drug list mean?

A tier is a price band: a drug on a lower tier usually costs you less than one on a higher tier, and each plan sets its own tiers.¹

Medicare gives this example, while warning that your plan’s tiers may differ:¹

Source: Medicare.gov, example of a Medicare drug plan’s tiers, checked Oct 14, 2026.¹

Employer plans use similar labels. Premera’s 4-tier list, for example, runs from 1 (generic) and 2 (preferred brand) to 3 (non-preferred brand) and 4 (specialty).²

Sometimes your prescriber thinks a lower-tier drug won’t do for you. A Medicare plan then lets you ask for a tiering exception: the lower tier’s cost-sharing for your higher-tier drug.^1,5

What do PA, ST and QL mean next to a drug?

They are the three common rules on a drug list: get approval first (PA), try another drug first (ST), or accept a cap on how much you get (QL).^2,3

Quantity limits sit on top of other rules, such as prior authorization, so a drug can carry several codes.² Indiana’s criteria, for example, also cap the Ozempic dose at 2 mg a week.⁴ Approval doesn’t last forever: there, a first approval runs up to 6 months and a renewal up to 1 year.⁴

For what a weight-management prior authorization usually asks for, see prior authorization, step by step.

What is a formulary exception, and when can you ask for one?

An exception asks your plan, for medical reasons, to cover a drug that isn’t on its list or to waive a rule.^1,5

Medicare’s rules are the clearest. Your prescriber must send a supporting statement saying one of these is true:⁵

• every covered drug on the list would be less effective for you, or would harm you;
• the amount allowed under a quantity limit has been, or is likely to be, less effective;
• the drug you were told to try first under step therapy has been, or is likely to be, less effective or harmful.

Once the plan has that statement, it must decide within 72 hours, or within 24 hours for a fast (expedited) request.⁵ The prescriber can give the statement by phone or in writing.⁵

Marketplace plans have a similar federal rule. It covers plans that must include the Affordable Care Act’s essential health benefits, which every Marketplace plan does.^6,7 The plan must answer a standard request within 72 hours.⁶ The limit is 24 hours when your health is in serious danger.⁶ The same applies if you’re partway through treatment with a drug not on the list.⁶ If it says no, you can ask for an independent review of that refusal.⁶

Other employer plans describe their own process in the summary plan description. That booklet explains how the plan works and how to file a claim.⁸

A worked example from an employer list: while Zepbound was off CVS Caremark’s main commercial lists, Caremark’s published exception criteria named Wegovy as the covered alternative.¹² They approved Zepbound after a poor response to Wegovy, side effects you can’t manage (intolerance) or a medical reason not to use it.¹² Records were required.¹² Approval lasted 12 months.¹² Caremark added Zepbound back as a preferred option on October 1, 2026, and employers can still customize their lists.¹³

How do step-therapy exceptions work, and what do state laws add?

Your prescriber asks the plan to skip the step, with reasons; in some states the law says when a plan must agree, and how fast.^3,14,15

For a Medicare plan, the prescriber’s statement says the cheaper drug would harm you or work less well. If approved, the plan covers the drug without you trying the cheaper one first.³

Read the plan’s criteria closely. Indiana Medicaid covers Mounjaro for type 2 diabetes only after two preferred GLP‑1s have failed, one of them Ozempic or Trulicity.⁴ The prescriber must then show at least 90 days on each, at a full working (optimized) dose, with lab results showing too little effect.⁴ Or they can give a medical reason to use Mounjaro instead.⁴ Its criteria also say stomach side effects don’t count as intolerance, because they are “expected class effects”.⁴

State laws. At least 36 states had laws limiting step therapy as of June 2024, though most apply only in certain cases.¹⁴ Two examples:

• New York lists five grounds for a step-therapy override. They include a required drug that is unsafe for you, expected not to work, or already tried.¹⁵ Another is a switch away from a drug you are stable on.¹⁵ Decisions are due within 72 hours, or 24 hours when your health is in serious danger.¹⁵
• Illinois barred step therapy in the plans it regulates from January 1, 2026. One insurer’s notice lists individual, student and fully insured group plans, and the State Employees Plan.¹⁶

State laws don’t reach self-funded plans, where the employer pays claims from its own funds.¹⁴ In 2025, 67% of workers with employer coverage were in self-funded plans.¹⁷ Your plan documents, or HR, can tell you which kind you have.

What do doctors send with an exception or step-therapy request?

Usually a short medical reason plus records that prove it: your diagnosis, recent lab results, and the names, doses and dates of drugs you’ve already tried.^4,5

Published criteria ask for the same kinds of evidence again and again. From the Medicare rule, Indiana’s criteria and Caremark’s exception document:

1. The prescriber’s statement giving the medical reason, in the terms the plan uses: less effective, harmful, or tried before.⁵
2. The diagnosis, confirmed by chart notes or claims history.⁴
3. Recent labs where the plan asks for them. Indiana wants an HbA1c (a 3-month blood sugar average) from the past 90 days.⁴
4. Earlier drugs, with dates. Each drug tried, the dose and the dates, from claims, chart notes or the prescriber’s signed statement, plus labs showing it didn’t work well enough.⁴
5. Side effects in the chart. Indiana counts an intolerance only if chart notes document it; Caremark marks its exception criteria “Documentation is required for approval”.^4,12

What a weight-management prior authorization asks for is set out in prior authorization, step by step. Medicare says plans may be able to handle prior authorization requests electronically from January 1, 2027.³

What happens if the plan turns the exception down?

A refusal is a coverage decision you can appeal, and the denial letter tells you how; the deadlines depend on the kind of plan you have.^5,18

• Medicare drug plans: ask for a redetermination within 65 days of the denial notice. A standard decision takes up to 7 days, and a fast one up to 72 hours.¹⁸
• Marketplace plans: you can ask an independent reviewer to look at a refused exception.⁶
• Employer plans: the denial notice must describe the plan’s review steps, including how to start an appeal.⁸

Each route, with its time limits, is set out in how GLP‑1 appeals work. New to a Medicare plan, or hit by a change to a drug you already take? Ask about a transition fill: a one-time 30-day supply.³

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