Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Pathway 1: Standard Weight Management (Group Benefit Pathway A)
All of:
- Age ≥ 18 years old
- Current baseline weight documented
- Physician attestation that member will participate in lifestyle modifications to promote weight loss (healthy eating, exercise if appropriate)
- Not to be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist containing products
Plus any one of:
- BMI ≥ 30 kg/m2 (obese)
- BMI ≥ 27 kg/m2 (overweight) with at least one weight-related comorbid condition (hypertension, type 2 diabetes mellitus, or dyslipidemia)
Pathway 2: Alternative Weight Management with Lifestyle Program (BMI ≥ 35)
All of:
- Age ≥ 18 years old
- BMI ≥ 35 kg/m2
- Documentation of current (within 30 days) baseline weight
- Documentation of active participation for a minimum of 6 months in a lifestyle modification program (e.g., food diaries, exercise logs, step counter reports, gym attendance logs, app participation demonstrating ≥ 10,000 steps/day or ≥ 150 minutes moderate-intensity physical activity/week)
- Documentation of current active participation in Teladoc Health Weight Management Program (must have met with a Teladoc weight management coach and have a plan of action)
- Must be prescribed by a PCP or provider with an established relationship with the member, seen in-person for evaluation and management of overall health
- Not to be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist containing products
- Will not be covered for members with Type 2 Diabetes Mellitus
Documentation to bring
- Current baseline weight
- Physician attestation that member will participate in lifestyle modifications to promote weight loss
- For Pathway 1: BMI documentation ≥ 30 kg/m2, or ≥ 27 kg/m2 with documentation of qualifying comorbidity (hypertension, T2DM, or dyslipidemia)
- For Pathway 2: BMI documentation ≥ 35 kg/m2
- For Pathway 2: Documentation of current (within 30 days) baseline weight
- For Pathway 2: Documentation of minimum 6 months active participation in a lifestyle modification program (food diaries, exercise logs, step counter reports, gym attendance logs, or fitness tracker data showing ≥ 10,000 steps/day or ≥ 150 min/week moderate-intensity activity)
- For Pathway 2: Documentation of current active participation in Teladoc Health Weight Management Program (record of meeting with Teladoc weight management coach and plan of action)
- For Pathway 2: Confirmation prescription is from PCP or provider with established in-person relationship with the member
- For continuation: Current weight (within 30 days)
- For continuation (Pathway 1): Physician attestation of ≥ 5% weight loss from baseline and continued active participation in lifestyle modifications
- For continuation (Pathway 2): Documentation of ≥ 5% weight loss from baseline; documentation of continued 6-month lifestyle modification program participation including Teladoc; current BMI ≥ 18.5 kg/m2; original BMI ≥ 35 kg/m2; proportion of days covered ≥ 80%
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Physician attestation that member maintains at least 5% weight loss from baseline; current weight must be submitted to plan; attestation of continued active participation in lifestyle modifications supporting weight loss.
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
- Type 2 Diabetes Mellitus (exclusion applies specifically to Pathway 2 only)
Policy note: Coverage criteria is determined by group benefit. Two distinct pathways exist: Pathway 1 (standard obesity/overweight with comorbidity, 1-year initial approval) and Pathway 2 (BMI ≥ 35, 6-month mandatory lifestyle program including Teladoc, 6-month initial approval, T2DM explicitly excluded). Continuation under Pathway 2 additionally requires: patient BMI was ≥ 35 kg/m2 prior to starting treatment, current BMI ≥ 18.5 kg/m2, and proportion of days covered ≥ 80%. The 'NC' notation in the document header indicates 'Not Covered' for some tier/plan context, but coverage criteria are provided, suggesting coverage is conditionally available subject to group benefit election. Revised date 06-01-2026.
Policy effective June 1, 2026 · verified June 2, 2026 · source: Prior Authorization And Step Therapy Guidelines · View policy document (PDF)