Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 35 or higher
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Adult weight loss - initial approval
All of:
- Age 18 years or older
- Baseline BMI >= 35 kg/m2
- Participated in comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity) with continuing follow-up for at least 6 months prior to drug therapy
- Used with reduced-calorie diet AND increased physical activity
Documentation to bring
- Baseline BMI documentation (>= 35 kg/m2)
- Documentation of participation in a comprehensive weight management program for at least 6 months prior to drug therapy
Quantity limits
- 2.5 mg/0.5 mL, 5 mg/0.5 mL, 7.5 mg/0.5 mL, 10 mg/0.5 mL, 12.5 mg/0.5 mL, 15 mg/0.5 mL — 2 mL (4 pre-filled single-dose pens) / 21 days; 6 mL (12 pre-filled single-dose pens) / 63 days (84-day)
Approval and renewal
- Initial approval: 8 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, Patient must have completed at least 3 months of therapy at a stable maintenance dose AND lost at least 5% of baseline body weight OR maintained initial 5% weight loss, and at least 12 weeks on therapy before the first renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Zepbound vials and Zepbound Kwikpens are covered under the LillyDirect manufacturer program and not under this policy
Policy note: Policy groups Zepbound and Mounjaro as 'tirzepatide (Zepbound/Mounjaro)' for both OSA and weight loss criteria. The quantity limits table lists 'tirzepatide (Zepbound/Mounjaro) pre-filled single-dose pens' for all strengths from 2.5 mg to 15 mg. Zepbound vials and Kwikpens are excluded from this policy and covered under LillyDirect program.
Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html