Which drug, and which indication
Coverage follows the FDA-approved indication, not the molecule. That is why the same active drug can be routine covered care under one brand and entirely uncovered under another.
| Drug | Approved for | Route that can bypass a weight-loss exclusion | Cash |
|---|---|---|---|
| Wegovy | Chronic weight management | Cardiovascular risk reduction in adults with established heart disease plus overweight or obesity | $349/mo for maintenance doses |
| Zepbound | Chronic weight management | Moderate-to-severe obstructive sleep apnea in adults with obesity | $299/mo (2.5 mg) |
| Ozempic | Type 2 diabetes | Already a non-weight indication — no statutory exclusion applies | $199/mo for the first 2 fills, then $349 (0.25/0.5/1 mg) or $499 (2 mg) |
| Mounjaro | Type 2 diabetes | Already a non-weight indication — no statutory exclusion applies | list $1,112/mo |
Prices are manufacturer self-pay figures as of September 2026 and change often — verify before relying on them. Asking for a diabetes brand to treat weight is off-label and usually forfeits the coverage route rather than saving money.
First: which kind of “no” do you have?
This single distinction saves more wasted effort than anything else on this page, and your denial letter states it.
Criteria denial — arguable
The plan covers the drug but decided you did not meet its requirements. Missing baseline weight, an undocumented prior therapy, a diagnosis code that never reached the form. These are usually paperwork problems and are frequently overturned.
Benefit exclusion — not arguable
Your plan does not cover that category at all. That is what your employer purchased, or what statute requires. No medical evidence changes it — recognise it early and change paths instead of appealing into a wall.
What each payer typically covers
From each payer's published posture. Your own plan document governs — two employers buying from the same insurer can reach opposite answers, which is why an insurer's general policy is a starting point rather than a verdict.
| Payer | Typically covered | Typically excluded |
|---|---|---|
| UnitedHealthcare (Commercial) | Ozempic for type 2 diabetes — typically considered for coverage on most UHC commercial PDLs with prior authorization and step therapy; verify with your specific plan and current formulary.; Mounjaro for type 2 diabetes — typically considered for coverage with prior authorization documenting T2D diagnosis and often a metformin trial; verify with your specific plan and current formulary.; Rybelsus (oral semaglutide) for type 2 diabetes — typically considered for coverage with prior auth; verify with your specific plan and current formulary.; Trulicity for type 2 diabetes — typically considered for coverage with prior auth; verify with your specific plan and current formulary.; Wegovy for chronic weight management — may be covered under plans that have not excluded weight-loss drugs and that meet BMI/comorbidity criteria; many ASO employer plans exclude this entirely; verify with your specific plan and current formulary.; Zepbound for chronic weight management or obstructive sleep apnea — coverage varies by plan and indication; verify with your specific plan and current formulary. | Off-label weight-loss use of Ozempic, Mounjaro, or Rybelsus — generally not covered; T2D documentation is typically required; Compounded semaglutide and tirzepatide — almost universally excluded from UHC commercial formularies as non-FDA-approved; Weight-loss GLP-1s (Wegovy, Zepbound) under employer ASO plans that have explicitly carved out anti-obesity medications; GLP-1s prescribed without documented prior-authorization criteria (BMI thresholds, comorbidities, prior therapy trials); Quantities exceeding plan-defined limits (e.g., more than one pen per month) |
| Anthem Blue Cross Blue Shield | Ozempic (semaglutide) for T2D — generally on formulary with PA requiring diabetes documentation; tier and step therapy vary by plan, verify with your specific plan and current formulary; Mounjaro (tirzepatide) for T2D — typically covered with PA, often step therapy through metformin first; verify with your specific plan and current formulary; Rybelsus (oral semaglutide) for T2D — usually formulary-listed with PA; verify with your specific plan and current formulary; Trulicity (dulaglutide) and Victoza (liraglutide) for T2D — commonly covered with PA; verify with your specific plan and current formulary; Wegovy (semaglutide) for weight management — may be covered on plans that include AOM benefit with PA (BMI ≥30 or ≥27 with comorbidity plus lifestyle program); many employer plans exclude — verify with your specific plan and current formulary; Zepbound (tirzepatide) for weight management or OSA — coverage varies widely; PA universally required when covered; verify with your specific plan and current formulary | Wegovy, Zepbound, Saxenda for weight loss under self-funded employer plans that have elected to exclude anti-obesity medications (common across large ASO employer groups); Off-label use of T2D GLP-1s (Ozempic, Mounjaro, Rybelsus) for weight loss without a T2D diagnosis — denied as not medically necessary; Compounded semaglutide and tirzepatide — generally not covered; Anthem follows FDA guidance treating compounded versions as not FDA-approved; Concurrent use of two GLP-1 receptor agonists — excluded per clinical policy; GLP-1s for patients not meeting documented BMI, comorbidity, or prior lifestyle intervention criteria in the plan's PA policy |
| Aetna (Commercial) | Ozempic for T2D when diabetes documentation criteria are met — verify tier and PA requirements with your specific plan and current formulary; Mounjaro for T2D under standard diabetes PA criteria — verify with your specific plan and current formulary; Rybelsus (oral semaglutide) for T2D on many formularies — verify with your specific plan and current formulary; Wegovy for chronic weight management on plans whose employer has elected anti-obesity drug coverage, subject to BMI/comorbidity PA — verify with your specific plan and current formulary; Zepbound for chronic weight management or, separately, for obstructive sleep apnea where the employer's plan covers it — verify with your specific plan and current formulary; Trulicity and Victoza for T2D where still on formulary — verify with your specific plan and current formulary | Weight-loss GLP-1s under self-funded employer plans that have carved out anti-obesity medications; Off-label use of T2D GLP-1s (Ozempic, Mounjaro) prescribed solely for weight loss without a T2D diagnosis; Compounded semaglutide or tirzepatide from 503A/503B pharmacies — Aetna generally does not cover compounded GLP-1s; GLP-1s prescribed outside FDA-approved indications and outside accepted compendia; Saxenda on many newer formularies where it has been displaced by Wegovy/Zepbound — verify with your specific plan and current formulary |
| Kaiser Permanente | Ozempic (semaglutide) for documented T2D, subject to regional formulary tier and step therapy — verify with your specific plan and current formulary; Mounjaro (tirzepatide) for documented T2D, often with prior authorization — verify with your specific plan and current formulary; Rybelsus (oral semaglutide) for T2D on select regional formularies — verify with your specific plan and current formulary; Trulicity (dulaglutide) for T2D where retained on the regional formulary — verify with your specific plan and current formulary; Wegovy or Zepbound for weight management only when your specific employer or individual plan includes an obesity-drug benefit and BMI/comorbidity criteria are met — verify with your specific plan and current formulary | Weight-loss GLP-1s (Wegovy, Zepbound, Saxenda) under Kaiser plans whose employer/benefit design excludes obesity pharmacotherapy; Off-label weight-loss prescribing of T2D-labeled GLP-1s (Ozempic, Mounjaro, Rybelsus) without a T2D diagnosis; Most Kaiser Senior Advantage (Medicare Advantage) coverage of GLP-1s for weight loss, per the Medicare Part D statutory exclusion (SSA §1860D-2(e)(2)(A)); Compounded semaglutide/tirzepatide, which Kaiser does not dispense through its in-house pharmacies; Brand-name GLP-1s when a preferred alternative exists and step therapy has not been completed |
| Medicare Part D | Ozempic (semaglutide) when prescribed for type 2 diabetes with documentation — coverage, tier, and PA requirements vary by plan; verify with your specific plan and current year formulary; Mounjaro (tirzepatide) when prescribed for type 2 diabetes with documentation — coverage and PA requirements vary by plan; verify with your specific plan and current year formulary; Rybelsus (oral semaglutide) when prescribed for type 2 diabetes with documentation — coverage varies by plan; verify with your specific plan and current year formulary; Wegovy (semaglutide) may be covered under Part D plans that have chosen to include it on formulary for the FDA-approved cardiovascular risk reduction indication (established CVD + overweight/obesity) following the 2024 SELECT-based label update; coverage is plan-specific and not guaranteed — verify with your specific plan and current year formulary; Zepbound (tirzepatide) may be covered under Part D plans that have chosen to include it on formulary for the FDA-approved moderate-to-severe obstructive sleep apnea indication in adults with obesity (2024 label update); coverage is plan-specific and not guaranteed — verify with your specific plan and current year formulary | Any GLP-1 prescribed solely for weight loss or chronic weight management — statutorily excluded under SSA §1860D-2(e)(2)(A); Wegovy prescribed for obesity without the cardiovascular risk reduction indication; Zepbound prescribed for obesity without the obstructive sleep apnea indication; Saxenda (liraglutide) prescribed for weight management — no separate non-weight-loss indication exists for this product; Off-label weight-loss use of Ozempic, Mounjaro, or Rybelsus in patients without documented type 2 diabetes; Compounded semaglutide or tirzepatide — generally not covered by Part D |
| Medicare Advantage (Part C with Part D / MA-PD) | Ozempic (semaglutide) when prescribed for type 2 diabetes with documented diagnosis — coverage and tier vary by plan formulary; verify with your specific plan and current formulary; Mounjaro (tirzepatide) when prescribed for type 2 diabetes with documented diagnosis — coverage varies by plan; verify with your specific plan and current formulary; Rybelsus (oral semaglutide) when prescribed for type 2 diabetes — coverage varies by plan; verify with your specific plan and current formulary; Wegovy (semaglutide 2.4 mg) MAY be covered by MA-PD plans that have chosen to include it on formulary specifically for the FDA-approved cardiovascular risk reduction indication (post-SELECT, 2024) in patients with established CVD and overweight/obesity; verify with your specific plan and current formulary; Zepbound (tirzepatide) MAY be covered by MA-PD plans that have chosen to include it on formulary specifically for the FDA-approved obstructive sleep apnea indication (2024) in adults with obesity; verify with your specific plan and current formulary | Any GLP-1 prescribed solely for weight loss or chronic weight management — statutorily excluded under SSA §1860D-2(e)(2)(A); Wegovy prescribed for weight management without the cardiovascular indication; Zepbound prescribed for weight management without the OSA indication; Saxenda (liraglutide) for weight loss; Off-label use of T2D GLP-1s (Ozempic, Mounjaro, Rybelsus) for weight loss without a T2D diagnosis; Compounded semaglutide or tirzepatide — generally not covered by Part D plans regardless of indication |
| Medicaid (general — varies by state) | Ozempic for T2D when on the state Preferred Drug List and clinical criteria are met — verify with your specific state Medicaid formulary and current PDL; Mounjaro for T2D when on the state PDL with prior authorization — verify with your specific state Medicaid formulary and current PDL; Rybelsus (oral semaglutide) for T2D where preferred or non-preferred with PA — verify with your specific state Medicaid formulary and current PDL; Wegovy or Zepbound for weight loss ONLY in the ~16 states that cover anti-obesity medications, subject to BMI and comorbidity criteria — verify with your specific state Medicaid program and current coverage policy | Weight-loss GLP-1s (Wegovy, Zepbound, Saxenda) in the majority of state Medicaid programs that have elected the §1927(d)(2) exclusion; Off-label use of T2D-indicated GLP-1s (Ozempic, Mounjaro) for weight loss without a documented T2D diagnosis; Compounded semaglutide and tirzepatide — Medicaid generally does not reimburse compounded versions of FDA-approved drugs; Coverage outside FDA-approved age ranges or without documented step therapy in states that require it |
| Federal Employee Program BCBS (FEP) | Ozempic (semaglutide) for type 2 diabetes with diabetes documentation — verify with your specific plan and current formulary; Mounjaro (tirzepatide) for type 2 diabetes with diabetes documentation — verify with your specific plan and current formulary; Rybelsus (oral semaglutide) for type 2 diabetes — verify with your specific plan and current formulary; Trulicity (dulaglutide) for type 2 diabetes — verify with your specific plan and current formulary; Wegovy (semaglutide) for chronic weight management under PA with BMI/comorbidity criteria, and potentially for cardiovascular risk reduction following the SELECT indication — verify with your specific plan and current formulary; Zepbound (tirzepatide) for chronic weight management under PA, and potentially for obstructive sleep apnea following the 2024 OSA indication — verify with your specific plan and current formulary; Saxenda (liraglutide) for weight management under PA in some plan options — verify with your specific plan and current formulary | Off-label weight-loss use of T2D-only GLP-1s (e.g., Ozempic, Mounjaro) without a diabetes diagnosis; Compounded semaglutide/tirzepatide from 503A/503B facilities (generally not covered by commercial plans including FEP); Cosmetic or non-medical weight-loss use without documented BMI/comorbidity criteria; GLP-1s prescribed without meeting plan-specific PA, step-therapy, or quantity-limit requirements; Drugs filled outside the FEP pharmacy network when network use is required by the plan option |
| Self-Funded Employer Plans (ASO) | Ozempic for T2D — typically covered with PA requiring A1c documentation; verify with your specific plan and current formulary; Mounjaro for T2D — typically covered with PA and often step therapy through metformin; verify with your specific plan and current formulary; Rybelsus for T2D — coverage varies, often non-preferred tier; verify with your specific plan and current formulary; Wegovy for cardiovascular risk reduction (post-SELECT indication) — may be covered by plans that include it for this indication; verify with your specific plan and current formulary; Zepbound for obstructive sleep apnea (OSA indication added 2024) — may be covered by plans that include it for OSA; verify with your specific plan and current formulary; Wegovy/Zepbound/Saxenda for weight management — coverage varies dramatically by employer; some cover with BMI ≥30 (or ≥27 with comorbidity) plus lifestyle-program enrollment, many exclude entirely; verify with your specific plan and current formulary | Anti-obesity medications under employers that have adopted a categorical AOM exclusion (common among cost-sensitive mid-market employers); Compounded semaglutide/tirzepatide — virtually universally excluded by PBMs as non-FDA-approved; Off-label weight-loss use of T2D-labeled GLP-1s (Ozempic, Mounjaro, Rybelsus) — PBM PA systems block weight-loss diagnoses; Coverage beyond a duration cap (e.g., 12- or 24-month lifetime maximum) imposed by some employers; GLP-1 use without completion of required lifestyle/wellness program prerequisites where mandated; Refills without documented weight-loss progress milestones (e.g., ≥5% loss at 6 months) where employer plan requires it |
| ACA Marketplace Plans | Ozempic when prescribed for type 2 diabetes with documented diagnosis — coverage and tier vary by issuer; verify with your specific plan and current formulary; Mounjaro when prescribed for type 2 diabetes with documented diagnosis — typically subject to prior authorization; verify with your specific plan and current formulary; Rybelsus (oral semaglutide) for type 2 diabetes — formulary placement varies widely; verify with your specific plan and current formulary; Wegovy may be covered by select marketplace plans that have added it for the FDA-approved cardiovascular risk reduction indication (post-SELECT trial, 2024) in adults with established CVD and overweight/obesity; verify with your specific plan and current formulary; Zepbound may be covered by select marketplace plans for the FDA-approved obstructive sleep apnea indication (2024) in adults with obesity and moderate-to-severe OSA; verify with your specific plan and current formulary; Saxenda (liraglutide) is rarely on marketplace formularies but occasionally included with prior authorization; verify with your specific plan and current formulary | GLP-1s prescribed solely for weight loss on plans that have adopted an anti-obesity drug exclusion (the majority of marketplace plans); Off-label use of T2D-indicated GLP-1s (Ozempic, Mounjaro, Rybelsus) for weight loss without a diabetes diagnosis; Compounded semaglutide or tirzepatide from non-FDA-approved sources — universally excluded by marketplace formularies; Brand GLP-1s when a preferred alternative is available and step therapy has not been completed; Quantity exceeding plan-defined limits without medical exception |
| Cigna (Commercial) | Ozempic (semaglutide) for type 2 diabetes may be considered for coverage; verify with your specific plan and current formulary; Mounjaro (tirzepatide) for type 2 diabetes may be considered for coverage; verify with your specific plan and current formulary; Rybelsus (oral semaglutide) for type 2 diabetes may be considered for coverage; verify with your specific plan and current formulary; Trulicity (dulaglutide) for type 2 diabetes may be considered for coverage; verify with your specific plan and current formulary; Wegovy (semaglutide) for chronic weight management or CVD risk reduction in adults with established cardiovascular disease may be considered for coverage on plans that include an anti-obesity rider; verify with your specific plan and current formulary; Zepbound (tirzepatide) for chronic weight management or moderate-to-severe obstructive sleep apnea in adults with obesity may be considered for coverage on plans that include the relevant rider; verify with your specific plan and current formulary; Saxenda (liraglutide) for chronic weight management may be considered for coverage when an anti-obesity benefit is included; verify with your specific plan and current formulary | Compounded semaglutide and tirzepatide — not FDA-approved as finished products and routinely excluded from Cigna/Express Scripts commercial benefits; Anti-obesity medications under employer groups that have elected an explicit weight-loss drug carve-out; GLP-1s prescribed off-label for cosmetic weight loss without a qualifying BMI or comorbidity diagnosis; Drugs obtained from non-network or international pharmacies outside the Express Scripts network; Quantity dispensed beyond formulary day-supply limits or maximum dose thresholds |
| Humana | Ozempic for type 2 diabetes with documented diagnosis and prior auth — may be considered for coverage; verify with your specific plan and current formulary; Mounjaro for type 2 diabetes with A1C documentation and typical step therapy — may be considered for coverage; verify with your specific plan and current formulary; Rybelsus (oral semaglutide) for type 2 diabetes — may be considered for coverage; verify with your specific plan and current formulary; Trulicity and Victoza for type 2 diabetes on certain Humana Part D and commercial tiers — may be considered for coverage; verify with your specific plan and current formulary; Wegovy for cardiovascular risk reduction in adults with established CVD and overweight/obesity, on plans that elect to cover the SELECT indication — may be considered for coverage; verify with your specific plan and current formulary; Zepbound for moderate-to-severe obstructive sleep apnea in adults with obesity, on plans that elect to cover the OSA indication — may be considered for coverage; verify with your specific plan and current formulary | Wegovy, Zepbound, and Saxenda when prescribed solely for weight loss under Humana Medicare Advantage Part D or stand-alone Part D plans (federal statutory exclusion); Off-label use of T2D GLP-1s (Ozempic, Mounjaro) for weight loss without a documented diabetes diagnosis; Compounded semaglutide and tirzepatide — not FDA-approved as finished products and not covered by Humana commercial or Part D plans; GLP-1 use in patients who do not meet plan-specific BMI, A1C, or comorbidity criteria; Coverage for indications outside the FDA label or outside CMS-recognized compendia for Part D |
| VA (Veterans Affairs / Veterans Health Administration) | Semaglutide (Ozempic) for type 2 diabetes when VA PBM criteria-for-use are met; may be considered for coverage; verify with your specific plan and current formulary.; Tirzepatide (Mounjaro) for type 2 diabetes when criteria-for-use are met and step-therapy with preferred agents is documented; may be considered for coverage; verify with your specific plan and current formulary.; Semaglutide (Wegovy) for chronic weight management when BMI, comorbidity, and prior intervention criteria are met and the veteran is engaged in a structured weight-management program; may be considered for coverage; verify with your specific plan and current formulary.; Tirzepatide (Zepbound) for chronic weight management or its FDA-approved obstructive sleep apnea indication when VA criteria-for-use are met; may be considered for coverage; verify with your specific plan and current formulary.; Oral semaglutide (Rybelsus) for type 2 diabetes when criteria are met; may be considered for coverage; verify with your specific plan and current formulary. | Compounded semaglutide and tirzepatide products — not FDA-approved as finished drug products and not dispensed through VA pharmacies.; GLP-1s prescribed without documented qualifying indication (e.g., cosmetic weight loss, BMI below threshold).; Prescriptions written by non-VA providers and filled outside VA pharmacy channels without Community Care authorization.; Branded products when a therapeutically equivalent VA-preferred agent has not been tried first, absent an approved exception.; Off-label use not supported by VA PBM criteria-for-use guidance. |
| TRICARE | Semaglutide (Ozempic) for type 2 diabetes with documented A1c and prior metformin trial — may be considered for coverage; verify with your specific plan and current formulary.; Tirzepatide (Mounjaro) for type 2 diabetes when step therapy criteria are met — may be considered for coverage; verify with your specific plan and current formulary.; Oral semaglutide (Rybelsus) for type 2 diabetes — may be considered for coverage; verify with your specific plan and current formulary.; Wegovy (semaglutide 2.4 mg) for chronic weight management with qualifying BMI and documented lifestyle intervention — may be considered for coverage; verify with your specific plan and current formulary.; Zepbound (tirzepatide) for chronic weight management or obstructive sleep apnea with obesity — may be considered for coverage; verify with your specific plan and current formulary. | Compounded semaglutide and tirzepatide — not FDA-approved as finished products and generally not covered by TRICARE.; GLP-1 prescriptions written for cosmetic weight loss without medical necessity or qualifying BMI/comorbidity documentation.; Quantities exceeding FDA-labeled dosing or refills outside formulary step therapy rules.; Use of weight-management GLP-1s without prior authorization or without an enrolled lifestyle/behavioral component when required. |
What a prior authorization asks for
The common pattern across major pharmacy benefit managers in 2026. Your plan publishes its own criteria, and you can request them in writing.
For weight-management brands (Wegovy, Zepbound):
- BMI at or above 30, or at or above 27 with a weight-related condition such as hypertension, dyslipidemia, sleep apnea or prediabetes.
- Baseline weight and BMI — not today's. This is the most common gap once someone has already lost weight on their own.
- Documentation of a lifestyle intervention, frequently around three months, recorded with dates.
- At reauthorization, evidence of response — commonly at least 5% weight loss — to continue.
For diabetes brands (Ozempic, Mounjaro):
- A documented type 2 diabetes diagnosis — this decides most requests.
- Recent A1c values, and often which glucose-lowering drugs were tried first.
- Whether metformin was tried, or why it was not appropriate.
- An off-label weight-loss request will generally be denied; the on-label product with the same molecule is the route that plans cover.
Per-drug detail: Wegovy · Zepbound · Ozempic · Mounjaro · the pillar
The three appeal routes
Which one applies depends on your payer type, and they differ substantially. The Medicare figures below are set in federal regulation, and several are widely published wrong.
Medicare Part D
- File within 60 calendar days of receiving the notice (42 CFR 423.582). The familiar “65 days” is a rebuttable presumption that you received it five days after its date — count 60 from the printed date.
- The plan decides in 7 calendar days (standard benefit), 14 days (payment/reimbursement) or 72 hours (expedited) — 42 CFR 423.590. The 14-day payment track is almost universally omitted elsewhere.
- A missed deadline is itself a denial, and the plan must forward your case to the Independent Review Entity within 24 hours. Do not refile.
- Your prescriber can act for you at levels 1 and 2 only. Beyond that they must be formally appointed as your representative.
- There is no minimum dollar amount at levels 1 or 2; the first threshold appears at the hearing level and is adjusted annually.
- For a formulary exception, the prescriber's supporting statement is the bottleneck — a missing one can add up to 14 days at the Independent Review Entity.
Medicaid
Administered by your state, so deadlines and the name of each step vary by where you live — unlike Medicare, this is not one federal ladder. Consistent rights: a written denial explaining the reason, a fair hearing, and in most states continued coverage while an appeal is pending if you file within the state's window. Because states set their own preferred drug lists, a denial here is often a formulary decision rather than a judgment about you, so a prescriber-filed exception usually beats a general appeal.
Commercial plans
An ACA-compliant plan owes you two levels: an internal appeal, then an independent external review by a reviewer the plan does not employ, whose decision binds the plan. You can also request, free of charge, the clinical criteria and full rationale used to deny you. A prescriber peer-to-peerreview — a direct call with the plan's medical reviewer — often resolves denials that stem from missing clinical context and is usually faster than a written appeal.
Step-by-step: appealing a GLP-1 denial · formulary and tiering exceptions
Before you file: the documentation checklist
Baseline weight and BMI
The starting figure, not today's. The single most common gap after someone has already lost weight on their own.
Diagnosis codes
For obesity and every qualifying comorbidity — hypertension, dyslipidemia, sleep apnea, prediabetes, cardiovascular disease.
Prior therapy with dates
Which drugs, what doses, how long, why each stopped. "Tried and failed" without dates is not documentation.
Documented intolerance
Recorded at the time it happened, not recalled afterwards.
The plan's own criteria
Request them in writing. It is hard to argue against a standard you have not read.
What to ask when you call your plan
Is this drug on my formulary, and at which tier?
Does it need prior authorization, and what exactly do you require to approve it?
Does my specific plan include weight-loss medication at all, or is it excluded from my benefit?
Is step therapy required, and which drugs count as having been tried?
What is my 30-day retail copay versus a 90-day mail-order copay?
Can you send me the written clinical criteria you use for this drug?
If you are on a federal program, the savings card will not work for you
If you are enrolled in Medicare (Part D or Advantage), Medicaid, the VA or TRICARE, a manufacturer copay or savings card will not work for you— and no pharmacist can override it. Federal anti-kickback law (42 U.S.C. § 1320a-7b) bars manufacturers from paying down copays for anyone in a federal healthcare program, and every GLP-1 savings card's own terms say so.
This matters because the card is the most heavily advertised way to make these drugs affordable, and people routinely enrol, assume it applies, and find out at the counter. Your levers instead are your plan copay, an exception or appeal, the manufacturer's separate cash and patient-assistance programs — which do not carry the same restriction — and, on Medicare, the GLP-1 Bridge.
Commercial and marketplace enrollees are unaffected — savings cards work normally for you.
If it stays uncovered
Before assuming cash is cheaper, price what the covered version would cost you — a denial that turns out to be a paperwork problem is often worth more than any discount. One more trap: introductory cash pricing covers starting doses and early fills — do not multiply it by twelve to budget a year.
Compare paths: cheapest GLP-1 · Medicare GLP-1 Bridge · TrumpRx self-pay prices · patient assistance · which insurers actually cover GLP-1s · why your plan routes you to a specialty pharmacy
Coverage is plan-specific and changes. This page describes common patterns and the statutory routes as of 2026-07-19 — it is information, not coverage, legal or medical advice. Your plan documents govern your situation; confirm details with your insurer.