Let’s Appeal / GLP-1 denials / Deadlines

Every GLP-1 appeal deadline, in one table

There are four appeal systems in America and you are in exactly one. They have different clocks. People lose winnable cases by counting from the wrong date or following the wrong track.

Verified against healthcare.gov, 29 CFR 2560.503-1, 29 CFR 2590.715-2719, 42 CFR 423 and 42 CFR 438 · last checked 2026-08-12

Two rules before any of the numbers matter.

1. Count from the date printed on the notice, not the day you opened the envelope, and not the day you decided to do something about it.

2. If your letter states a different deadline than the tables below, your letter governs. A plan may give you more time than the legal floor. It may never give you less.

Get my exact date, free

Upload your letter and we compute the actual calendar date with days remaining. No account, no card.

First: which track are you on?

One phone call settles it. Call the member number on your card and ask: "Is my plan self-funded or fully insured?" Write down the date, the time, and who told you.

That question matters more than it sounds. About 67% of covered workers are in self-funded plans, and at large employers it is roughly 80% (KFF, 2025 Employer Health Benefits Survey). In a self-funded plan your employer pays the claims and the insurance company only administers them, which changes who can actually say yes and whether state law protects you at all.

The deadlines

Track A: marketplace plans and fully insured job plans

Step	Your deadline	Their deadline
Internal appeal	180 days	30 days pre-service, 60 post-service, 72 hours urgent
External review	4 months	45 days, or 72 hours expedited

The external review is the strongest right you have and the most underused. An Independent Review Organization that does not work for your insurer decides, and the decision binds the plan. Only about 40% of consumers know it exists.

Track B: self-funded employer plans (ERISA)

Step	Your deadline	Their deadline
Internal appeal	at least 180 days	72 hours urgent, 30 days pre-service, 60 days post-service, per level
Document request	no deadline	on request, free of charge
External review	4 months	45 days, or 72 hours expedited

The document right is the part nobody uses. Under 29 CFR 2560.503-1 you are entitled, on request and free of charge, to copies of all documents relevant to your claim, including the internal criteria the plan actually applied to you. Here is the letter that asks for it.

The thing that trips everyone on this track: state insurance mandates generally do not apply to self-funded plans. If your state passed a law about weight-loss drug coverage, it probably does not reach you. Aim at your employer instead, since they wrote the benefit design.

Track C: Medicare Part D

Step	Your deadline	Their deadline
Coverage determination or exception	n/a	72 hours, or 24 hours expedited
Redetermination	60 calendar days	7 days for a benefit request, 14 for a payment request, 72 hours expedited
IRE reconsideration	60 calendar days	same clock as the plan
ALJ hearing	60 calendar days	subject to an amount-in-controversy minimum

Three details that are commonly reported wrong:

The 7 versus 14 day split is benefit request versus payment request, not "exceptions versus everything else."
Receipt of the redetermination is presumed to be 5 calendar days after the date printed on it, so your real IRE window is usually 65 days from that date.
The IRE does not get 30 days. That is the Medicare Advantage figure. Part D runs on the same clock the plan did.

If the plan misses its own deadline, the regulation treats that as a denial and requires the case be forwarded to the IRE within 24 hours. Note the date they were due.

The Medicare GLP-1 Bridge is a separate door, and it has no deadlines of this kind. It runs through December 31, 2027, costs a flat $50 copay, does not require a Part D denial first, and its criteria are measured at the time you started therapy, not today.

It also has no appeals process at all. Those are CMS's words. If a Bridge request is denied, the only remedy is your prescriber resubmitting with corrected or additional information, so the first submission is the one that counts. Confirm current terms at medicare.gov/glp1bridge.

Track D: Medicaid managed care

Step	Your deadline	Their deadline
Plan appeal	60 calendar days	30 calendar days, or 72 hours expedited
Continuation of benefits	10 days	fills continue while the appeal runs
State fair hearing	90 to 120 days	set by your state

The 10-day window catches almost everyone. If you are currently getting the medication filled and you want that to continue while you appeal, you generally have to ask within 10 days of the notice. Nobody volunteers this.

What if the deadline already passed?

You have not lost everything, and this is worth reading rather than assuming.

A fresh prior authorization is usually not time-barred. A new request with documentation you did not have the first time gets reviewed on its own merits.
Many plans accept late appeals for good cause. Ask. The worst answer is no.
The next plan year resets the question entirely, and open enrollment is when you can change the answer by changing the plan.

Get your actual date

These are the rules. Your date is a specific day on a calendar, and working it out from a letter is exactly the sort of thing that goes wrong at 11pm when you are upset.

Read my letter and compute my deadline

Free. No account. We do not keep your document.

If you want the whole process after that, the four tracks taught properly, the document request, the evidence file, the letters and the escalation ladder, that is The Denial Playbook: GLP-1 Edition. $99, and it is not required to use anything on this page.