A Zepbound denial from your insurer is a decision you can challenge, and federal rules set the deadlines on both sides. Group health plans and health insurance issuers must run an internal claims and appeals process and an external review process[1]. The same rules apply to Wegovy, or to any prescription drug your plan decides on.
Whether your plan lists Zepbound at all, and on what criteria, is covered in is Zepbound covered by insurance. This page starts where that one stops: the letter says no.
First, read what kind of denial it is
A prior authorization request is a pre-service claim. The rule defines that as a claim where the plan makes receiving the benefit depend on approval in advance[2]. The plan must decide it within 15 days of receiving it[2]. It may extend once, by up to 15 days, if it tells you why before the first 15 days run out[2]. An urgent claim must be decided within 72 hours[2].
HealthCare.gov lists the grounds a plan might give. They include that the benefit isn’t offered under your plan, or that the requested treatment is “not medically necessary”[4]. Both can be appealed internally[4]. They split later, at external review, so note which one your letter uses.
What the denial letter must tell you
The notice must set out the specific reason for the denial and the specific plan provisions it rests on[2]. It must describe any extra information you could send to perfect the claim, and why that information is needed[2]. It must describe the review procedures and their time limits[2].
If the plan relied on an internal rule, guideline or protocol, the notice must include it. Or it must say one was used and that you can get a copy free on request[2]. Ask for it before you write the appeal: it shows what the plan measured the request against.
The clock, step by step
| Step | Who acts | Deadline in the rule |
|---|---|---|
| Prior authorization decision (pre-service claim) | Plan | 15 days after receiving the claim, one 15-day extension allowed |
| Urgent claim decision | Plan | 72 hours |
| File the internal appeal | You or your representative | At least 180 days after the denial notice |
| Decide the internal appeal, pre-service | Plan | 30 days with one appeal level; 15 days per level with two |
| Decide an urgent appeal | Plan | 72 hours |
| File for external review | You or your representative | Four months after the denial or final denial |
| Preliminary review of the request | Plan | Five business days |
| External review decision | Independent review organization | 45 days; 72 hours if expedited |
Filing the internal appeal
You must be given at least 180 days after receiving the denial to appeal[2]. HealthCare.gov states the same window as 180 days, or six months[4]. You may submit written comments, documents and records, and the review must take all of them into account, even if they were not part of the first decision[2].
You are entitled, free of charge, to reasonable access to and copies of every document relevant to your claim[2]. The appeal cannot defer to the first denial, and it must be decided by someone other than the person who denied it, or that person’s subordinate[2]. Where the denial turns on medical judgment, including whether a drug is medically necessary, the reviewer must consult a health care professional[2].
HealthCare.gov says to complete your insurer’s forms, or write with your name, claim number and insurance ID number, and to add anything you want considered, such as a letter from your doctor[4]. Your state’s Consumer Assistance Program can file the appeal for you[4].
How fast the plan must answer
For a pre-service appeal, a plan with one appeal level must decide within 30 days of receiving your request[2]. A plan with two levels must decide each within 15 days[2]. An urgent appeal must be decided within 72 hours[2]. An individual-market insurer may have only one level of internal appeal before its final decision[1].
If the plan relies on new evidence or a new rationale, it must give it to you free and in time to respond before its final decision[1]. If a plan fails to strictly follow the internal appeal rules, you are treated as having exhausted them and may go straight to external review[1]. That does not apply to minor violations that caused no harm and had good cause[1].
External review, and the medical-judgment line
After a final internal denial, you can ask for external review within four months of receiving the notice[1]. The plan has five business days to check the request is eligible[1]. The independent review organization then has 45 days to decide[1]. If it reverses the denial, the plan must immediately provide coverage or payment[1].
The federal process covers denials that involve medical judgment, such as medical necessity, appropriateness or effectiveness of a covered benefit, as decided by the external reviewer[1]. HealthCare.gov describes the same scope: any denial involving medical judgment where you or your provider may disagree with the plan[5]. A letter that says Zepbound is not medically necessary for you fits that description. A letter that says the plan simply does not include weight-loss drugs reads as a benefit exclusion, and the reviewer decides whether medical judgment is involved.
When the timeline for a standard review would seriously jeopardize your life or health, or your ability to regain maximum function, you can request expedited review[1]. The reviewer must then decide within 72 hours[1]. HealthCare.gov adds that in urgent cases you may file the internal appeal and the external review request at the same time[4].
External review through the HHS-administered process is free[5]. A plan using a contracted reviewer or a state process may charge, but no more than $25 per review[5]. Your final denial letter names who handles your external review[5].
When Zepbound is not on the formulary at all
A formulary exception is a separate request from an appeal. Under 45 CFR 156.122, a health plan providing essential health benefits must let you, your designee or your prescriber request clinically appropriate drugs not otherwise covered[3]. The plan must decide a standard exception request within 72 hours[3]. An expedited request, based on exigent circumstances, must be decided within 24 hours[3].
Exigent circumstances include a condition that may seriously jeopardize your life, health or ability to regain maximum function. They also include a current course of treatment using a non-formulary drug[3]. If the plan refuses, you can have the request and the refusal reviewed by an independent review organization, on the same 72-hour or 24-hour clock[3]. A granted standard exception covers the drug for the length of the prescription, refills included[3].
If a plan stops covering a drug you already take
A plan must keep coverage in place while you appeal[1]. Under the claims rule, cutting short an approved ongoing course of treatment is itself a denial you can appeal before the benefit ends[2]. That protection has a stated exception: a reduction or termination “by plan amendment or termination”[2]. When an employer removes weight-loss drugs from the plan itself, the continued-coverage rule does not reach it.
Which plans these rules reach
Section 147.136 applies to group health plans and health insurance issuers[1]. It generally does not apply to grandfathered plans, apart from external review of certain out-of-network emergency and air ambulance claims[1]. Medicare coverage works differently and is set out in does Medicare cover Zepbound. Military coverage is in does TRICARE cover Wegovy.
While the appeal runs
Keep copies of the denial, your appeal, every document you send and notes of each phone call, with the date, time and name of the person you spoke to[4]. If you fill the prescription yourself while waiting, the maker’s cash terms are in Zepbound savings card and Zepbound price, and the Wegovy terms are in Wegovy savings card. The one question to ask the plan on the first call: which guideline did you apply, and will you send me a copy?