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 (hypertension, type 2 diabetes mellitus, and dyslipidemia)
- 3 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Initial approval - weight management
All of:
- Patient is 18 years of age or older
- History of participation in a medically supervised weight loss program (low-calorie diet, increased physical activity, behavioral modifications) for at least 3 months prior to initiating therapy
- Patient is currently on and will continue a weight loss program of low-calorie diet, increased physical activity, and behavioral modifications
- Requested agent will NOT be used in combination with another GLP-1 receptor agonist
- Requested dose is within FDA approved dosage limits
- Requested agent will NOT be used in combination with another weight loss agent
Plus any one of:
- BMI >= 30 kg/m2 (obesity diagnosis)
- BMI >= 27 kg/m2 with at least one weight-related comorbidity/risk factor (e.g., diabetes, dyslipidemia, coronary artery disease)
Documentation to bring
- Documentation of BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with qualifying comorbidity
- Documentation of at least 3-month history of participation in a medically supervised weight loss program (low-calorie diet, increased physical activity, behavioral modifications)
- Attestation that patient is currently on and will continue a weight loss program
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and Provider must attest that patient has achieved and maintained weight loss >= 5% from baseline (prior to initiation of requested agent). Patient must be currently on and will continue a weight loss regimen. The 3-month medically supervised program requirement is not re-verified at renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Combination with another GLP-1 receptor agonist not permitted
- Combination with another weight loss agent not permitted
- Bariatric surgery
Policy note: Zepbound added to policy 04-01-2024. Policy description incorrectly labels Zepbound as liraglutide; Zepbound is actually tirzepatide. The weight loss criteria apply under the shared 'Target Agent(s)' framework.
Policy effective July 1, 2023 · verified June 2, 2026 · source: policy-211.html