What to say when you call your insurer

Novo Nordisk's Wegovy insurance guide (US26NC00145, August 2026) tells patients to "Call the number on the back of your insurance card." If the plan requires prior authorization, it suggests asking: "Can you send me a document with all the criteria I must meet before Wegovy® is covered?" Other questions it lists: "What are the covered indications or conditions Wegovy® can treat? Are there special diagnostic codes for them?", "Do I need to try another medicine before my plan will cover Wegovy®?", "What documents do you need my doctor to send?" and "What is my out-of-pocket maximum?"

Novo Nordisk, "Ready to talk to your insurance company about Wegovy?" insurance coverage guide, effective August 2026 · source

The member-facing warning is much softer than the policy language, and it names who runs the drug benefit. Aetna's commercial clinical program summary tells members: "Your plan may not cover certain drugs to treat conditions such as infertility, erectile dysfunction and weight loss." The same document states that "Pharmacy benefits are administered by an affiliated pharmacy benefit manager, CVS Caremark" and that "Aetna® is part of the CVS Health® family of companies."

Aetna, "2026 Aetna Commercial Clinical Program Summary", effective 2026 · source

Express Scripts' prior authorization page: "Prior Authorization criteria is available upon request." Its general request form is for when "you would like to request a coverage determination (such as a step therapy exception) or if you would like to make an appeal for us to reconsider a coverage decision."

Express Scripts (Evernorth), Prior Authorization Resources · source

CVS Caremark's prior authorization page: "The term prior authorization may be used by the plan to also include exception reviews for quantity limitations, step therapy protocol and/or non-formulary drug coverage." When one is needed, "the member will be asked to have their health care provider" contact the Caremark Prior Authorization Department "to answer criteria questions to determine coverage."

CVS Caremark, Prior Authorization · source

HealthCare.gov, internal appeals: "You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied." Keep "Notes and dates from any phone conversations you have with your insurance company or your doctor that relate to your appeal. Include the day, time, name, and title of the person you talked to and details about the conversation."

HealthCare.gov (Centers for Medicare & Medicaid Services), Internal appeals · source

Medicare.gov, appeals in a Medicare drug plan: "you have the right to a coverage determination, either orally or written, to see if a drug is covered. Contact your plan to get a coverage determination." You can "Call your plan." "If you're asking for an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved."

Centers for Medicare & Medicaid Services, Medicare.gov: Appeals in a Medicare drug plan · source

Aetna states when its own criteria stop applying. Its weight reduction policy notes that "Many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan," and continues: "The medical necessity criteria set forth below do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control. Under these plans, claims for weight loss drugs will be denied based on this exclusion." The policy's history records a last review of 03/10/2026.

Aetna, Medical Clinical Policy Bulletin 0039, "Weight Reduction Programs and Devices", effective February 2000 · source

Where the plan used an internal criterion, you can have it for nothing. The notice must give either the rule itself or "a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request." Where the denial rests on medical necessity or an experimental exclusion, the notice must give "an explanation of the scientific or clinical judgment for the determination, applying the terms of the plan to the claimant's medical circumstances," or a statement that it will be provided free of charge on request.

29 CFR §2560.503-1(g)(1)(v), Electronic Code of Federal Regulations, effective August 2026 · source

Health coverage carries extra notice requirements the general rule does not. The plan must ensure the notice includes "information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable), and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning)." It must also ensure the stated reason "includes the denial code and its corresponding meaning, as well as a description of the plan's or issuer's standard, if any, that was used in denying the claim," and for a final internal denial "this description must include a discussion of the decision." It must "provide a description of available internal appeals and external review processes, including information regarding how to initiate an appeal," and "disclose the availability of, and contact information for, any applicable office of health insurance consumer assistance or ombudsman."

45 CFR §147.136(b)(2)(ii)(E), Electronic Code of Federal Regulations, effective August 2026 · source

On appeal your file is yours, free. The plan must "Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits." Relevant is defined widely: it includes anything that "Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon," and any plan "statement of policy or guidance with respect to the plan concerning the denied treatment option or benefit for the claimant's diagnosis."

29 CFR §2560.503-1(h)(2)(iii) and (m)(8), Electronic Code of Federal Regulations, effective August 2026 · source

On Medicare Part D a prescriber needs no appointment at all for the steps that matter. The agency states: "The enrollee's prescribing physician or other prescriber may request a coverage determination, redetermination or IRE reconsideration on the enrollee's behalf without having to be an appointed representative."

Centers for Medicare & Medicaid Services, Part D appeals forms, effective July 2026 · source