GLP-1 Denial Appeal Letters: Templates by Reason for Denial

Start here: the denial letter names your fight

An appeal only works if it answers the reason the plan actually gave. Every adverse determination has to state the specific reason and the plan provision it rests on, so the first job is to read that sentence and match it to a template below rather than writing a general plea. A letter arguing that the drug works will lose to a plan that denied on a missing BMI value.

This is educational, not legal or medical advice. Your clinician sends the clinical letter; you send the procedural one, and the combination is what moves a file.

The deadlines, from the regulation

These are federal minimums for employer-sponsored plans under the ERISA claims procedure rule. Your plan may be faster. It may not be slower.

Two things worth knowing before you spend an evening on this. First, an external review is not advisory: your insurer is required by law to accept the external reviewer's decision². Second, denials at this stage are ordinary rather than exceptional — in a national all-payer study of more than two million first fill attempts for single-source branded drugs, 14.8% were rejected for formulary exclusion and 17.2% for prior authorization or step therapy, and formulary-based rejections rose from 24.3% in 2018 to 40.7% in 2024³.

Before you write: assemble four things

• The denial letter, with the stated reason and the plan provision quoted.
• The plan's prior authorization criteria document — you are going to answer it line by line.
• Your clinician's chart notes covering the diagnosis, measurements and prior attempts.
• Dates. Every call, every fax, every name.

Send it in writing, keep the transmission receipt, and put your member ID and claim number in the first line of every page.

Template 1 — denied for "not medically necessary"

"I am requesting an internal appeal of the denial dated [date] for [drug], claim number [number]. The denial states the medication is not medically necessary. My treating clinician has diagnosed [condition] and has documented [measurement or clinical finding] in the enclosed chart notes dated [date]. The prescription is for an FDA-approved indication of this product. I am asking that the plan apply its own published criteria, which I have enclosed, to the enclosed documentation, and that any denial on review identify which specific criterion is unmet."

Template 2 — denied because the benefit is excluded

"The denial states that anti-obesity medications are excluded under my plan. I am requesting a copy of the plan document language creating that exclusion, and confirmation of whether the exclusion applies to this prescription given that it was written for [the specific labeled indication documented by my clinician] rather than for weight reduction alone. If the exclusion applies as written, I am requesting that this letter be treated as a request for a formulary exception under the plan's exception process, and I am asking for the criteria the plan applies to such exceptions."

Template 3 — denied for step therapy

"The denial states I must first try [alternative]. My clinician has documented [tried and discontinued for stated reason / contraindicated because of stated reason] in the enclosed notes. I am requesting an exception to the step therapy requirement on that basis, and I am asking that the plan state, in any adverse determination on review, which alternative it considers appropriate and on what clinical basis it concluded the documented history does not satisfy the requirement."

Template 4 — denied for missing documentation

"The denial cites missing information. Enclosed are [list each item and its date]. I am asking that the claim be reprocessed with these records. Under the plan's claims procedure I am entitled, free of charge, to copies of all documents, records and other information relevant to my claim, and I am requesting them, including any internal rule, guideline or protocol relied upon in the denial."

Template 5 — denied a specific brand while another is covered

"The denial indicates that [drug A] is not covered while [drug B] is. My clinician prescribed [drug A] for [the labeled indication and clinical reason documented in the enclosed notes]. I am requesting a formulary exception. If the plan maintains the denial, please identify the covered alternative it considers therapeutically equivalent for this indication and the clinical evidence supporting that determination."

That last one is common enough to have its own guide — see what to do when your plan covers one GLP-1 and not the other, and read formulary exclusions and step therapy before you choose between an exception request and an appeal.

Two sentences to add to every letter

Ask for the file, and preserve your next move. Add: "Please provide all documents, records and other information relevant to this claim, including any internal rule or guideline relied upon." And: "If this appeal is denied, please provide written notice of my right to external review and the contact information for the independent review organization."

After the internal appeal

If the final internal denial arrives, you have four months to request external review, the standard decision comes within 45 days, and an expedited review is decided within 72 hours where the medical urgency warrants it². If the answer is still no, the cash lane is a decision rather than a defeat: start with how to get a GLP-1 without insurance and the shortlist on our cheapest GLP-1 board, and if you paid out of pocket while appealing, read how to file a superbill for reimbursement.

The decisive takeaway

Match the template to the stated reason, answer the plan's own criteria line by line, send it in writing before the 180-day window closes, and ask for the claim file in the same letter. If the internal appeal fails, external review is binding on the insurer and costs you a form. Some links here earn us a referral fee, which never changes the ranking.