Wegovy & Zepbound appeal letter sample
A free fill-in letter for a job-based or individual plan that denied prior authorization for Wegovy or Zepbound, with what to attach and the deadlines your plan must meet.
Disclosure: We sell the GLP-1 Appeal Kit. Money You're Owed makes it, and if you buy it we earn money. We don't take payment from anyone else mentioned here. This page is general information for US readers, not legal advice.
This page gives you one free sample letter for the most common situation: a job-based or individual (Marketplace or off-exchange) health plan denied prior authorization for Wegovy or Zepbound. Everything in [square brackets] is for you to fill in from your own denial letter and records. Leave out anything you cannot document.
The rules your plan has to follow
These federal rights apply to most job-based and individual plans. "Grandfathered" plans (plans in place before March 23, 2010 and not materially changed) are mostly exempt. Group plans and their insurers must follow the federal ERISA claims rule, 29 CFR 2560.503-1.
- Time to appeal: you get at least 180 days from the denial notice to file an internal appeal.
- Prior-authorization requests: the plan must decide a pre-service request within 15 days, and can extend this once, by up to 15 days. An urgent request must be decided within 72 hours.
- Appeal decisions: for a prior-authorization (pre-service) appeal, within 30 days with one appeal level, or within 15 days per level if the plan has two levels. If you have already paid or filled (post-service), within 60 days with one level, or within 30 days per level.
- Urgent appeals: decided within 72 hours of the plan receiving your appeal (29 CFR 2560.503-1). Your doctor decides whether the request is urgent, and the plan must accept that.
- What the denial letter must say: the specific reason, the plan provision it relies on, and what extra information would complete the claim. If the plan used an internal rule or criterion, the letter must include it or say you can get it free of charge.
- Your file: you can see the claim file and submit evidence, and any new evidence or reasons the plan uses must be given to you free of charge. You can ask, free of charge, for copies of everything relevant to your claim.
- Individual plans have one level of internal appeal.
For the full sequence from first denial to external review, see the GLP-1 denial appeal ladder and how to appeal a GLP-1 denial.
Free sample appeal letter: commercial plan, prior-authorization denial
[Your full name]
[Address] · [Phone] · [Email]
[Date]
[Plan or insurer name]
Attn: Appeals
[Appeals address or fax from your denial letter]
Re: Internal appeal of prior-authorization denial
Member: [name] · Member ID: [ID] · Claim or reference number: [number]
Date of request: [date] · Prescriber: [name] · Drug and strength: [drug, strength]
I am appealing the denial of prior authorization for [drug, strength], dated [date of denial letter].
The denial reason. Your letter states: "[quote the exact denial reason]". It cites [quote the plan provision named in the letter].
Why the request meets the plan's requirements. [Drug] is prescribed for [the use your prescriber wrote]. Its current FDA label states that it is indicated [quote the indication from the current label; for Zepbound, the label says it is indicated in combination with a reduced-calorie diet and increased physical activity “to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition”, and "to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity"]. [List each criterion the denial says was not met, and point to the enclosed record that shows it.]
Enclosed. I am submitting written comments, documents, records, and other information in support of this appeal: [numbered list of enclosures].
Requests. Please send me, free of charge, the internal rule, guideline or criterion used to make this decision, and a copy of my claim file. Please send me a written decision within the deadline that applies to this appeal.
[If urgent:] My treating prescriber, [name], certifies that this request is urgent. I am requesting an expedited appeal and, at the same time, expedited external review.
If this appeal is denied, I intend to request external review.
Sincerely,
[Signature]
[Printed name]
What to attach
- A copy of the denial letter.
- Your prescriber's letter supporting the request.
- Records showing [BMI history], [weight-related conditions], and [prior therapies tried, with dates], exactly as they appear in your chart. Do not estimate or fill in anything that is not documented.
- A numbered list of every enclosure, matching the list in the letter.
- A note of how and when you sent the appeal (fax confirmation, upload receipt or tracking number).
Not sure your plan covers the drug at all? Start with the free GLP-1 denial checklist.
If the internal appeal is denied: external review
- If the plan doesn't follow the rules above, you can go straight to external review.
- Ask for external review within 4 months of the final denial. An independent reviewer (IRO) decides within 45 days, or within 72 hours if expedited. You can ask for expedited external review at the same time as an urgent internal appeal.
- Your denial notice says where to request external review.
- If the reviewer overturns the denial, the plan must cover it right away.
- For an ongoing course of treatment, coverage continues while the appeal is pending.
- For job-based (ERISA) plans, the denial notice must also tell you about your right to sue after the appeal.
When this letter is the wrong one
- Medicare Part D. A Part D denial goes through your plan's own process: ask the plan for a redetermination within 65 days from the date on the initial denial notice (per Medicare.gov). See Zepbound denied: what to do for the Part D steps.
- Medicare GLP-1 Bridge. The Bridge has no appeals process; the prescriber can resubmit the prior authorization with corrected or additional information.
- Grandfathered plans are mostly exempt from these federal appeal rules. Your plan documents say whether yours is one.
Frequently asked questions
How long do I have to file an internal appeal?
For a job-based plan, the federal claims rule gives you at least 180 days from the denial notice to appeal. Check your own denial notice for the exact deadline it states.
How fast must an urgent appeal be decided?
Within 72 hours of the plan receiving your appeal, under 29 CFR 2560.503-1. Your doctor decides whether the request is urgent, and the plan must accept that.
Can I see the rules the plan used to deny the request?
Yes. If the plan relied on an internal rule or criterion, the denial letter must include it or say you can get it free of charge. You can also ask, free of charge, for copies of everything relevant to your claim.
What if my internal appeal is denied?
You can ask for external review within 4 months of the final denial. An independent reviewer decides within 45 days, or within 72 hours if expedited. Your denial notice says where to request external review.
Does this letter work for a Medicare GLP-1 Bridge denial?
No. CMS says there is no appeals process under the Medicare GLP-1 Bridge; the prescriber can resubmit the prior authorization with corrected or additional information.