Employer / Commercial Insurance
Depends on your plan's benefitPatient must have anti-obesity medication coverage benefits (criterion 7 of initial criteria; criterion 4 of continuation criteria)
What you need to qualify
- Age 18 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (CVD, CAD, HTN, OSA, knee_osteoarthritis, T2DM, dyslipidemia, PCOS, NASH/NAFLD, asthma, and COPD)
- BMI of 25 or higher for patients of Asian descent
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Adult weight loss — obesity (BMI >= 30)
All of:
- Patient is 18 years of age or older
- Diagnosis of obesity AND BMI >= 30 kg/m2
- Requested medication will NOT be used concurrently with another GLP-1 receptor agonist
- Requested medication will NOT be used concurrently with another weight loss medication
- Provider has addressed requirement for lifestyle modifications
- Patient has anti-obesity medication coverage benefits
Plus any one of:
- Patient was unable to achieve acceptable weight loss (1 lb/week) through lifestyle modifications over 6 months
- Patient has a weight-related comorbidity that warrants immediate medication intervention
Adult weight loss — Asian descent (BMI >= 25)
All of:
- Patient is 18 years of age or older
- Diagnosis of obesity AND BMI >= 25 kg/m2
- Patient is of South Asian, Southeast Asian, or East Asian descent
- Requested medication will NOT be used concurrently with another GLP-1 receptor agonist
- Requested medication will NOT be used concurrently with another weight loss medication
- Provider has addressed requirement for lifestyle modifications
- Patient has anti-obesity medication coverage benefits
Plus any one of:
- Patient was unable to achieve acceptable weight loss (1 lb/week) through lifestyle modifications over 6 months
- Patient has a weight-related comorbidity that warrants immediate medication intervention
Adult weight loss — overweight with comorbidity (BMI >= 27)
All of:
- Patient is 18 years of age or older
- BMI >= 27 kg/m2
- At least one weight-related comorbidity/risk factor (e.g., CVD, CAD, HTN, OSA, knee-osteoarthritis, T2DM, dyslipidemia, PCOS, NASH/NAFLD, asthma, COPD)
- Requested medication will NOT be used concurrently with another GLP-1 receptor agonist
- Requested medication will NOT be used concurrently with another weight loss medication
- Provider has addressed requirement for lifestyle modifications
- Patient has anti-obesity medication coverage benefits
Plus any one of:
- Patient was unable to achieve acceptable weight loss (1 lb/week) through lifestyle modifications over 6 months
- Patient has a weight-related comorbidity that warrants immediate medication intervention
Documentation to bring
- Baseline BMI documentation
- Documentation of obesity diagnosis or weight-related comorbidity
- For Asian descent patients: documentation of ancestry (South Asian, Southeast Asian, or East Asian)
- Documentation that provider addressed lifestyle modification requirement
- Documentation of 6-month lifestyle modification attempt with failure to achieve 1 lb/week weight loss, OR documentation of weight-related comorbidity warranting immediate medication intervention
- Documentation that patient is not concurrently using another GLP-1 receptor agonist
- Documentation that patient is not concurrently using another weight loss medication
- Confirmation of anti-obesity medication coverage benefits
Quantity limits
- 2.5 mg/0.5 mL — 4 pens per 28 days
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and Adults: weight loss >= 5% from baseline (prior to initiation). Patient must retain anti-obesity medication coverage benefits. Initial BMI, lifestyle, and comorbidity criteria are not re-verified at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Concurrent use of another GLP-1 receptor agonist
- Concurrent use of another weight loss medication
- Non-formulary products require Non-formulary Exception Criteria
Policy note: Zepbound added to policy November 2023. Step requirement removed April 2024. Only the 2.5mg titration dose has an explicit quantity limit; maintenance doses do not have a listed quantity limit per May 2024 update. Zepbound does not have a listed pediatric (12-17) indication in this policy. Quantity limit exception criteria allows a 90-day titration period override.
Policy effective July 1, 2026 · verified July 16, 2026 · source: Pa policy