Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (CVD)
- Established cardiovascular disease (established_cardiovascular_disease)
Qualification pathways
You can qualify through any one of these.
CV Risk Reduction in Adults with Established CVD and Obesity/Overweight
All of:
- Established cardiovascular disease
- Obesity (BMI >= 30 kg/m2) OR overweight (BMI >= 27 kg/m2)
- Used in combination with reduced calorie diet and increased physical activity
- Current baseline weight documented
- Physician attestation that member will participate in lifestyle modifications
- Not to be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist-containing products
Documentation to bring
- Documentation of established cardiovascular disease
- Physician attestation of BMI >= 30 kg/m2 (obese) or >= 27 kg/m2 (overweight)
- Documentation of current baseline weight
- Physician attestation of member participation in lifestyle modifications (reduced calorie diet and increased physical activity)
- Attestation that medication will not be combined with other weight loss products
- Attestation that medication will not be combined with other GLP-1 agonist-containing products
- For continuation: Physician attestation that member maintains >= 5% weight loss from baseline
- For continuation: Current weight submission
- For continuation: Attestation of continued active participation in lifestyle modifications
- For continuation: BMI >= 18.5 kg/m2
Approval and renewal
- Initial approval: 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and For adults (obesity/CV risk reduction): 5% weight loss from baseline, current weight submission, attestation of continued active participation in lifestyle modifications, BMI >= 18.5 kg/m2. CV disease establishment and other initial criteria are not explicitly re-verified at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Cannot be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist-containing products
Policy note: The CV risk reduction pathway is explicitly listed as a separate qualification route for adults with established cardiovascular disease. The policy does not specify particular CV qualifying events (e.g., MI, stroke, PAD) beyond 'established cardiovascular disease.' No exclusion of patients with diabetes is stated. Continuation uses the same criteria as the obesity/overweight continuation pathway (5% weight loss from baseline).
Policy effective June 1, 2026 · verified June 2, 2026 · source: prior-authorization-and-step-therapy-guidelines.pdf