How to Request a Formulary Exception to Get GLP-1 Medications Like Zepbound or Wegovy Covered for Weight Loss

Here’s a clear, step-by-step guide on how to request a formulary exception, especially helpful for patients trying to get coverage for a GLP-1 like Zepbound when it’s not on their plan:

Step 1: Call your insurance or pharmacy benefit manager (PBM)

Ask if there’s a way to request a formulary exception or non-formulary coverage request for your medication. You can usually find the PBM name and number on the back of your insurance card.

Step 2: Ask your doctor to submit the request

The formulary exception must be submitted by a prescriber. Tell your doctor’s office exactly which medication was denied and why. Ask them to include:

• The specific diagnosis (e.g., obesity, type 2 diabetes)

• Why the covered alternative (like Wegovy) is not appropriate or effective for you

• Any supporting records (like prior adverse effects, failure of alternatives, etc.)

Step 3: Make sure your provider uses the right form

Many insurers have specific prior authorization or formulary exception forms on their website. Search for “[Your PBM or insurance] formulary exception form” or call and ask where your doctor should fax or submit it.

Step 4: Follow up relentlessly

Call your insurance or PBM every few days to check the status. These decisions often take 3 to 10 business days. Keep a record of:

• Every call (date, name of rep, what was said)

• Any reference numbers or case IDs

• Your doctor’s fax or submission confirmation

Step 5: Be ready to appeal

If the exception is denied, you can often appeal. You may also qualify for a continuation of care exception if you were already taking the drug before it was removed from coverage.

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