Medicare Part D Zepbound coverage appeal

Medicare Part D prior authorization criteria for Zepbound

• •Anti-obesity use EXCLUDED by federal law (Social Security Act §1860D-2(e)(2)(A))
• •Diabetes use COVERED if Ozempic/Mounjaro/Rybelsus prescribed for T2D
• •Cardiovascular risk reduction with semaglutide (Wegovy, FDA-approved Mar 2024 for CV indication) is increasingly covered

Step-by-step appeal flow

1. 1

   Pull your carrier policy bulletin

   Medicare Part D publishes its Zepbound coverage criteria. Read it first — every successful appeal cites it back to the reviewer.

2. 2

   Document your medical necessity

   Anti-obesity use EXCLUDED by federal law (Social Security Act §1860D-2(e)(2)(A)) Diabetes use COVERED if Ozempic/Mounjaro/Rybelsus prescribed for T2D Cardiovascular risk reduction with semaglutide (Wegovy, FDA-approved Mar 2024 for CV indication) is increasingly covered

3. 3

   Have your prescriber submit the PA

   Most Medicare Part D PAs go through CoverMyMeds or the carrier portal. Your prescriber attaches BMI history, comorbidities (with ICD-10 codes), lifestyle program participation, and prior weight-loss attempts.

4. 4

   If denied — file the appeal within 60 days

   For Wegovy/Zepbound (weight-only): cannot appeal — federal law excludes. For Wegovy CV-risk indication: appeal citing FDA-approved cardiovascular indication + patient meets SELECT criteria.

5. 5

   Submit external review if internal appeals fail

   After two internal appeals, you can request external review through your state insurance commissioner. ERISA plans go through the federal external-review process.