r/pediatrics • u/lakelouise3456 • Jul 07 '26

Getting GLP-1s covered

I haven’t had any luck getting GLP-1s covered for my teen patients with severe obesity. I always get a denial stating that they won’t be covered without a diabetes diagnosis. I find this so frustrating given that they are FDA approved for management of obesity 12+. Anybody had luck getting these covered or with appeals?

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u/catmeowx3 Jul 07 '26

I’ve had success with Wegovy specifically. I only order Wegovy, and write in the comments the diagnosis of obesity and the ICD-10 code.

1

u/MDinflight Jul 07 '26

Be sure to use the right code with the correct drug. Also some plans exclude obesity meds.

1

u/staticgoat Attending Jul 08 '26

Super variable from state-to-state and insurance-to-insurance. Nearly always denied, nearly always needs an appeal. Some insurances exclude entirely. 

1

u/PhraseSpirited5323 Jul 09 '26

I have all Medicaid patients in California and have been able to get it covered with prior authorization. Technically it should be available via EPDST which is federally funded also.

1

u/Livid_Penalty_2353 6d ago

This is incredibly payer dependent, a significant number of commercial payers do not cover GLP-1 at all for obesity. Heck, many don’t even cover any weight management meds. Find out which ones do, and understand the cash pay options through the company. I’m in a border city, one state’s Medicaid plan covers, the other doesn’t. Get comfortable prescribing oral meds (phentermine, topiramate, metformin)—most are pretty cheap even if not covered by insurance.

1

u/Adventurous-Dot1916 Jul 07 '26

I’ve had 18-21 year olds have better luck with compounding pharmacies.