How to Get Express Scripts to Approve Wegovy Fast

If you’ve tried to get Wegovy through Express Scripts, you already know it's not always smooth sailing. Even if your doctor says you need it, the hoops you have to jump through can feel endless. So, what’s their deal?

Wegovy isn’t just expensive—it’s in high demand, and insurance companies set some tough rules before they’ll pick up the tab. Express Scripts likes to see medical documentation, previous attempts with cheaper drugs, and proof that you meet specific requirements. Missing just one detail can turn a quick yes into a hard no.

The best thing you can do early on is get organized. Know exactly what Express Scripts wants before your doctor sends anything. This can save weeks—and a lot of frustration. Stick around, because I’m going to show you how to dodge the common traps people fall into and actually boost your odds of getting an approval.

• Why Express Scripts Denies Wegovy
• Steps Before You Even Apply
• How to Nail the Prior Authorization
• Dealing With Denials and Appeals
• Insider Tips That Make a Difference

Why Express Scripts Denies Wegovy

If you've gotten a rejection from Express Scripts for Wegovy, you're definitely not alone. These guys turn away a lot of requests from people who honestly qualify—or should. They use strict criteria that are a bit of a moving target. Not knowing the exact requirements can cost you time and peace of mind.

So, why does Express Scripts say no so often? One big reason is that they follow narrow guidelines for who counts as medically eligible. They're strict about BMI cutoffs. Right now, they’ll only consider Wegovy if your body mass index is at least 30, or at least 27 if you also have certain weight-related health conditions (like type 2 diabetes, hypertension, or high cholesterol). If your medical records aren’t crystal clear on these numbers, you’re probably getting denied.

Another common reason is not trying other weight loss methods first. Express Scripts almost always wants proof that you’ve tried diet, exercise, and less costly medications—like generic phentermine or orlistat—before stepping up to something as pricey as Wegovy. Forget to document that, and they’ll kick it right back.

Even paperwork mistakes can sink your request fast. If your doctor’s notes or insurance forms are missing info (like your exact BMI, latest lab results, or what other treatments you’ve tried), Express Scripts won’t hunt you down—they’ll just deny it and tell you to try again.

• Missing medical documentation: Not showing a history of weight loss attempts.
• Doesn’t meet strict BMI thresholds: BMI not high enough or no evidence of related medical conditions.
• Trying Wegovy first: No proof of trying cheaper medicines first.
• Sloppy paperwork: Incomplete forms, missing signatures, or test results.

Back in 2024, claims data showed that up to 60% of first-time requests for GLP-1 weight loss drugs like Wegovy got denied due to incomplete information or missing past-therapy proofs. This is why prepping every detail upfront matters so much.

The good news? A little extra effort beats another ‘NO’ letter. Understanding the reasons for denial is key to getting that approval on the next try.

Steps Before You Even Apply

Getting ahead of the process is key if you want Express Scripts to approve your Wegovy prescription. One miss, and you’re back at square one, starting over with more paperwork. Here’s how to front-load your odds for a smooth ride:

• Check Your Insurance Policy — Dive into your benefits. Wegovy is often only approved if your plan has obesity coverage. Some workplace insurance plans and certain Medicaid plans cover it, while lots of others don’t. Don’t just assume—ask your insurer, “Is Wegovy on my drug list and do you require prior authorization?”
• Know Your BMI & Medical History — Almost all plans with Wegovy coverage require a BMI over 30, or over 27 with a qualifying health issue like high blood pressure or diabetes. Your doctor needs this info because Express Scripts won’t go off your word—they’ll want numbers and details straight from your file.
• Document Previous Weight Loss Meds — Insurance likes to see you’ve given cheaper meds a try. Have a list of brands you’ve used (like Saxenda, Contrave, or even just diet and exercise plans) and how long you took them. Your doctor should write these down, even if you didn’t get much benefit.
• Talk to Your Doctor Early — If your doctor is new to prescribing Wegovy, share with them what Express Scripts wants. Ask for copies of your chart notes that mention your BMI, previous meds, and why other options failed.

If you’ve got all this before you even ask your doctor to submit, you’re way less likely to get a quick denial. It takes some prep, sure, but it saves you headaches later. Don't forget to make copies for your own records—miscommunication happens all the time at big pharmacy benefit managers like Express Scripts.

How to Nail the Prior Authorization

Getting prior authorization for Wegovy from Express Scripts is all about showing you really need it and have already tried cheaper meds. The biggest reason people get denied? Missing paperwork or not having solid proof in their medical history. Here’s how you can actually boost your chances on the first try:

• Meet their criteria: Express Scripts wants to see a BMI of 30+, or 27+ with at least one weight-related condition—think type 2 diabetes, high blood pressure, or sleep apnea. If you’re not hitting these numbers, the approval is almost always a no-go.
• Document past efforts: You need proof you’ve tried other weight loss methods. This means notes showing you’ve failed diet, exercise, or cheaper weight-loss prescriptions like phentermine or Contrave. Sometimes they want to see at least 6 months of these attempts. If nothing’s in your chart, ask your doctor to add a summary.
• Have a clear doctor’s letter: A short, clear note from your doctor that spells out your BMI, your weight-related conditions, and your past medication fails can be a game changer. Express Scripts cares more about facts than fluff, so get straight to the point.
• Use the right codes: Doctors should use current ICD-10 codes—E66.9 for obesity, for example—and include any other relevant diagnosis. Missing or wrong codes can slow this process down or get you an instant denial.
• Double check the form: Always look up Express Scripts’ latest prior auth form for Wegovy. Rules can change every year, so using last year’s form or skipping questions is risky.

Want to know just how strict they are? Across the board, about 60% of Wegovy prior authorizations are denied on the first attempt. That’s mostly due to incomplete info. Nail these details, and you’ll already have an edge.

The more organized your doctor is, the better. Stay on top of every part—they won’t chase you for missing info. It’s on you (and your doctor) to make sure every box gets checked.

Dealing With Denials and Appeals

So Express Scripts shot down your Wegovy request? You’re not alone. About 60% of initial requests for brand-name weight loss meds like Wegovy get denied on the first attempt. But don’t give up—you’ve still got a solid shot if you know what to do next.

First, read the denial letter carefully. There’s usually a reason, and it's often something that you or your doctor can fix. The letter almost always lists what’s missing or why they said no. Sometimes, it’s as simple as missing paperwork, not meeting BMI cutoffs, or lacking a history of trying other weight loss drugs first. Knowing their exact reason saves time when you go back for the appeal.

Here’s how to handle the appeal step by step:

1. Call your doctor’s office right away. Ask them for a copy of everything they sent to Express Scripts, plus the denial letter if you didn’t already get it.
2. Double-check what Express Scripts requires for Wegovy approval. Usually, they want a BMI above 30, or above 27 with a weight-related issue like diabetes or high blood pressure, plus records of past failed attempts at dieting or cheaper meds.
3. Have your doctor write an appeal letter. This should clearly state your medical history, past treatments, and why Wegovy is a medical necessity. It helps to include any records that prove you’ve done what they ask—like notes about failed weight loss programs or other meds you’ve tried.
4. Submit all documents at once. Make sure you include the denial letter, the appeal, supporting medical records, office notes, and any extra letters explaining your case. The fewer back-and-forth emails or faxes, the better.
5. Follow up. After a week, call Express Scripts and check that they got all the paperwork. Get a reference number for your appeal so you’re not lost in the system. If you use the online portal, keep screenshots showing what you upload and when.

If they deny you again, don’t panic—many people have to appeal more than once. You can sometimes request a “peer-to-peer” review, where your doctor speaks directly to an Express Scripts medical reviewer and makes the case by phone. This has worked for a lot of folks, especially if regular appeals hit a wall.

Check out these quick facts about appeals timelines:

Here’s the thing: persistence pays off. Keep records, follow up, and don’t be afraid to involve your HR department if your medication coverage comes through work. Sometimes a push from your employer can speed things up if Express Scripts is dragging their feet.

Insider Tips That Make a Difference

There are little things people miss that separate a quick approval from months of back-and-forth. Here’s what really works for getting Wegovy covered with Express Scripts.

• Get your doctor’s notes right, the first time: Ask your doctor to spell out your BMI, any weight-related conditions (like high blood pressure or diabetes), past weight-loss attempts, and a specific statement that Wegovy is medically needed. Coding matters—double-check that they use the official diagnosis codes.
• Bring up STEP studies: Some Express Scripts reps look for references to official clinical trials, like the STEP 1 and STEP 2 trials that got Wegovy FDA-approved. If your doctor can mention your situation lines up with those studies, it can help.
• Log all medications you’ve tried: Don’t just say “failed weight loss.” List all other meds or programs you tried, how long you tried them, and why they didn’t work. The more details, the better.
• Call Express Scripts directly: As soon as your prescriber submits the prior auth, call member services. Ask if anything is missing, double-check the status, and get the name or ticket number of the rep you talked to. This paper trail comes in handy if something gets lost or delayed.
• Be persistent but polite: Stay on top of both your doctor’s office and Express Scripts every week. Approvals sometimes get stuck just because nobody pushed.

Small habits—like keeping all paperwork together and following up regularly—turn what feels impossible into something you can actually pull off. And if you get denied, don’t let up. File an appeal with even more documentation, and consider asking your HR or benefits manager to go to bat for you if it’s under an employer plan. A surprising number of approvals come through on appeal, especially when you’re prepared and can show you did everything by the book.