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Was your GLP‑1 denied? Build your appeal letter

For a denied Ozempic, Wegovy, Zepbound or other GLP‑1: get an appeal letter, a request for the plan's criteria and your claim file, a request to your prescriber, a checklist of attachments, and the deadlines that apply, worked out from the date on your notice.

Takes about 2 minutes Nothing you type leaves your device Every deadline cites its rule
A template, not legal advice. Your plan's own denial notice wins: it names the deadline and the address that apply to you. If it differs from what you see here, follow the notice.Information only, not a promotion. Every medicine named here is prescription-only. Only a prescriber can decide whether one is right for you and prescribe it. We don't recommend, rank or favor any medicine. Where we list several, they're in alphabetical order. We don't sell medicines or take money from drug companies.
Step 1 of 5Coverage
What kind of coverage denied it?

The rules and deadlines depend on this. It's usually on your insurance card or at the top of the denial notice. Not sure? Choose "Not sure" and we'll show how to tell.

Which medicine, and what was it prescribed for?

The letter names both. The use matters: plans often treat weight, diabetes, heart, sleep apnea and liver uses differently.

Medicine
Prescribed for
What reason does the denial give?

Look for a line such as "reason for denial" or "criteria not met". Pick the closest.

Which decision is this?
What date is on the denial notice?

We use it to work out your deadlines. Use the date printed on the letter (not the day it arrived): that gives the earlier, safer date.

Which records do you already have?

Tick what you can lay your hands on. The checklist marks the rest as "to get", and the letters only promise what you have.

Next you'll see your dates and four documents. Every line can be edited before you print, save as PDF or copy.

Private by design: the letters are built in your browser. Nothing is sent or stored unless you choose to email them to yourself, and nothing goes in the link. Your name and member ID are optional: you can add them on the next screen or leave the blanks to fill on paper. Privacy notice

Your appeal packet is ready

Your detailsType them once and they fill the yellow blanks in every letter. Optional, and not saved: close the tab and they're gone.

You can change any wording. Click or tap into a letter and type. Your changes go into the PDF, the Word file, the copy and the email. Going back to “Edit answers” rebuilds the letters, so make wording changes last.

GLP-1 appeal packet

What happens next

    What this means

    What this doesn't mean

    • It isn't legal advice, and it can't promise a result. The plan, the independent reviewer or the hearing officer decides. A strong letter mostly helps by sending the evidence the criteria ask for.
    • The dates aren't a promise either. They come from the federal rules. Your plan, your state or your notice can set a different date, and the notice is the one to follow.
    • It doesn't say the medicine is right for you. That's your prescriber's call. Don't start, stop or change a medicine because of a coverage decision without talking to them.

    Why we say this

    The rule behind each date and each request in your packet, with its source. All checked Oct 14, 2026.

      Read next

      How this works

      You answer up to 5 short questions, and all of them are optional. The tool then fills four documents from fixed templates. It doesn't need your name, member ID or claim number. The letters leave blanks such as [Member ID]: type your details once on the results screen to fill them, or fill them in on paper. Either way they stay in your browser.

      The deadlines come from the federal rules for each kind of coverage. Employer and Marketplace plans must allow at least 180 days after a denial for an internal appeal, and then 4 months for an external review after the final denial.1,2 A Medicare drug plan gives 65 days from the date on the notice.3,4 A Medicaid health plan gives 60 days to appeal to the plan, then 90 to 120 days after its decision to ask for a state fair hearing; when the state agency itself denies it, the state sets a fair-hearing deadline of up to 90 days.5,6 TRICARE gives 90 days and FEHB plans 6 months.7,8

      We count from the date printed on the notice. Most rules count from the day you receive it, which is later, so our date is the earlier, safer one. Where a month has no matching day (4 months after October 30 has no February 30), the external-review rule says to use the first day of the next month. If that falls on a weekend or federal holiday, the rule moves it to the next business day.1,9

      The records lists follow published criteria, not guesses: CVS Caremark's tirzepatide criteria, Indiana Medicaid's GLP‑1 criteria and the Medicare GLP‑1 Bridge rules for prescribers.10,11,12 Your own plan's criteria may differ, which is why one document asks the plan for them.

      What this can't tell you

      • Your exact deadline. Only your plan's notice can, because plans and states can allow longer, and the clock usually starts when you receive the notice.
      • Whether your appeal will succeed. That depends on your plan's terms and your records.
      • Whether your plan covers weight-loss drugs at all. If it excludes them, an appeal usually can't add them.13

      Questions people ask

      How long do I have to appeal a GLP‑1 denial?

      It depends on the kind of coverage. Employer and Marketplace plans must allow at least 180 days after you receive the denial for an internal appeal.1,2 A Medicare drug plan gives 65 days from the date on the notice to ask for a redetermination.4 A Medicaid health plan gives 60 days from the date on the notice, then 90 to 120 days after its decision for a state fair hearing; when the state agency itself denies it, the state sets the fair-hearing time, up to 90 days.5,6 TRICARE gives 90 days and FEHB plans 6 months.7,8 The deadline printed on your own notice is the one that applies.

      Is this letter legal advice?

      No. It is a template built from the federal rules and published plan criteria, with blanks for your details. Your plan's own notice and documents decide your deadlines and rights. For free help: a State Health Insurance Assistance Program (SHIP) for Medicare, your state's consumer assistance program or insurance department, or the Department of Labor's benefits advisors at 1-866-444-3272 for employer plans.14,15

      Can an appeal make my plan cover Wegovy or Zepbound for weight loss if the plan excludes it?

      Usually not. An appeal asks the plan to apply its own rules correctly; it can't add a benefit the plan leaves out.13 Medicare Part D plans can't cover drugs used for weight loss alone by law; the Medicare GLP‑1 Bridge is the route for weight.16,12 If the medicine is prescribed for another approved use, such as heart risk, sleep apnea, MASH or type 2 diabetes, the letter asks the plan to review it under that use.

      What should my doctor's letter of medical necessity include?

      The diagnosis, the measurements and test results the plan's criteria ask for (for example BMI with the date it was measured, a sleep study, HbA1c or a liver scan), past weight programs and medicines tried with dates, why the requested medicine is needed, and why the plan's alternatives would not work or would cause harm.10,11 The tool lists what fits your use and denial reason. Our prior authorization checklist goes further.

      Can I get the plan's criteria and my claim file?

      For employer and Marketplace plans, the federal claims rules say the plan must give you, on request and free of charge, the criteria it relied on and copies of all documents relevant to your claim.2 Medicaid health plans must give you your case file free of charge.5 The tool writes this request for you.

      Is anything I type saved or sent?

      No. The letters are built inside your browser. Nothing is sent or stored, and nothing goes in the link. If you add your name, member ID or other details to fill the blanks, they stay on this page and are gone when you close it. The only exception is if you choose to email the letters to yourself: then they go once through our email provider and aren't kept. See the privacy notice.

      Sources

      1. 45 CFR 147.136, internal claims and appeals and external review processes (Affordable Care Act; includes the 4-month external-review rule, the "first day of the fifth month" example and the weekend and holiday extension). eCFR, up to date as of Oct 8, 2026. ecfr.gov. Checked Oct 14, 2026.
      2. 29 CFR 2560.503-1, claims procedure (Department of Labor; 180 days to appeal, decision times, free copies of criteria and claim documents). eCFR, up to date as of Oct 8, 2026. ecfr.gov. Checked Oct 14, 2026.
      3. 42 CFR Part 423, Subpart M, Medicare Part D grievances, coverage determinations, redeterminations and reconsiderations (§§ 423.568, 423.572, 423.582, 423.590, 423.600). eCFR, up to date as of Oct 8, 2026. ecfr.gov. Checked Oct 14, 2026.
      4. Medicare.gov. Appeals in Medicare drug plans (Part D): 65 days to ask for a redetermination; 7 days standard, 72 hours expedited; 5 levels. medicare.gov. Checked Oct 14, 2026.
      5. 42 CFR 438.402, 438.406 and 438.408, Medicaid managed care appeals (60 days from the date on the notice; 30-day and 72-hour decisions; fair hearing 90 to 120 days after the plan's decision; free case file). eCFR, up to date as of Oct 8, 2026. ecfr.gov. Checked Oct 14, 2026.
      6. 42 CFR 431.221 and 431.244, Medicaid fair hearings ("a reasonable time, not to exceed 90 days from the date that notice of action is mailed"; decisions ordinarily within 90 days; expedited within 3 working days). eCFR, up to date as of Oct 8, 2026. ecfr.gov. Checked Oct 14, 2026.
      7. TRICARE. Appeals (90 days from the decision for a first appeal, including pharmacy prior authorization denials sent to Express Scripts; 60 or 90 days for later levels, by appeal type), and 32 CFR 199.10, appeal and hearing procedures. tricare.mil · ecfr.gov. Checked Oct 14, 2026.
      8. 5 CFR 890.105, FEHB filing claims and the disputed claims process (6 months to ask the plan to reconsider; plan answers within 30 days; 90 days to ask OPM to review). eCFR, up to date as of Oct 8, 2026. ecfr.gov. Checked Oct 14, 2026.
      9. 5 U.S.C. 6103, federal holidays, and the Office of Personnel Management's federal holidays page (holidays falling on a Saturday are observed the Friday before; on a Sunday, the Monday after). law.cornell.edu · opm.gov. Checked Oct 14, 2026.
      10. CVS Caremark. Tirzepatide prior authorization criteria with quantity limit, reference 6947-C (P08-2025 v4): weight program for 6 months, baseline BMI, 5% weight loss to renew, sleep study for sleep apnea. PDF. Checked Oct 14, 2026.
      11. Indiana Medicaid (prepared by OptumRx). GLP-1 receptor agonists and combinations: prior authorization criteria, July 1, 2026 (type 2 diabetes, heart, MASH and sleep apnea uses). PDF. Checked Oct 14, 2026.
      12. CMS. Medicare GLP-1 Bridge: information for prescribers (prior authorization decision within 72 hours; "If you believe a denial was made in error, you may resubmit the prior authorization for re-review"). Product No. 12235, June 2026. PDF. Checked Oct 14, 2026.
      13. HealthCare.gov. Internal appeals and external review (180 days; 30 days for a service not yet received; urgent cases "at least within 4 business days"; external review within 4 months, decided within 45 days or 72 hours; the plan must accept the decision). healthcare.gov · healthcare.gov. Checked Oct 14, 2026.
      14. U.S. Department of Labor, Employee Benefits Security Administration: benefits advisors, 1-866-444-3272. dol.gov. Checked Oct 14, 2026.
      15. Medicare.gov. Get help with appeals, including your State Health Insurance Assistance Program (SHIP). medicare.gov. Checked Oct 14, 2026.
      16. Social Security Act § 1927(d)(2)(A): drugs used for weight loss may be excluded, applied to Medicare Part D by § 1860D-2(e)(2). law.cornell.edu. Checked Oct 14, 2026.
      17. 45 CFR 156.122(c), exception requests for drugs not on the formulary (plans covering essential health benefits: 72 hours, or 24 hours when urgent; external exception review). ecfr.gov. Checked Oct 14, 2026.
      18. Express Scripts for TRICARE. Are GLP-1 and weight loss medications covered through the TRICARE pharmacy benefit? (weight-loss medications covered for TRICARE Prime and Select with prior authorization; not for other beneficiaries from Aug 31, 2025). militaryrx.express-scripts.com. Checked Oct 14, 2026.
      19. US prescribing information (FDA labels): Wegovy (Novo Nordisk, revised June 2026), Zepbound and Mounjaro (Eli Lilly, revised August 2026), Ozempic (May 2026), Rybelsus, and Foundayo (July 2026). Wegovy · Zepbound · Mounjaro · Ozempic · Rybelsus · Foundayo. Checked Oct 14, 2026.

      Last checked Oct 14, 2026 · Next review due Jan 14, 2027

      How this tool was made. Written by the GLP Guidebook team from the sources above. It's general information, not legal or medical advice. Your plan's notice and documents decide your rights and deadlines. Talk to your doctor or another licensed prescriber before starting, stopping or changing any medicine. In an emergency, call 911. How we write