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BCBS Wyoming · Weight Loss

BCBS Wyoming coverage for Zepbound (Weight Loss)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 12 and older
  • BMI of 30 or higher
  • BMI of 27 or higher with a weight-related condition (hypertension, T2DM, OSA, CVD, and dyslipidemia)
  • BMI of 25 or higher for patients of Asian descent
  • BMI at or above the 95th percentile for age and sex
  • 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Adult weight management (BMI >= 30)

All of:

  • Patient is an adult (18 years of age or over)
  • BMI >= 30 kg/m^2
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • Patient has NOT tried a targeted weight loss agent (e.g., Saxenda, Wegovy, Zepbound) in the past 12 months
  • Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy

Adult weight management (BMI >= 25 - Asian descent)

All of:

  • Patient is an adult (18 years of age or over)
  • Patient is of South Asian, Southeast Asian, or East Asian descent
  • BMI >= 25 kg/m^2
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • Patient has NOT tried a targeted weight loss agent in the past 12 months
  • Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy

Adult weight management (BMI >= 27 with comorbidity)

All of:

  • Patient is an adult (18 years of age or over)
  • BMI >= 27 kg/m^2
  • At least one weight-related comorbidity/risk factor/complication (e.g., hypertension, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, dyslipidemia)
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • Patient has NOT tried a targeted weight loss agent in the past 12 months
  • Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy

Pediatric weight management (age 12-17)

All of:

  • Patient is pediatric (12 to 17 years of age)
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • BMI >= 95th percentile for age and sex
  • BMI >= 30 kg/m^2
  • BMI >= 85th percentile for age and sex AND at least one weight-related comorbidity/risk factor/complication (e.g., hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea)

Documentation to bring

  • Documentation of BMI >= 30 kg/m^2 (or >= 27 with comorbidity, or >= 25 if Asian descent, or BMI percentile for pediatric patients)
  • Documentation of 6-month weight loss regimen (low-calorie diet, increased physical activity, behavioral modifications)
  • Documentation of weight-related comorbidity if using the 27 kg/m^2 threshold
  • Documentation of ancestry if using the 25 kg/m^2 Asian threshold
  • Documentation that obesity is not restricted from coverage under the patient's benefit

Quantity limits

  • 2.5 MG/0.5 ML vial — 4 Vials per 180 days (84-day)
  • 5 MG/0.5 ML vial, 7.5 MG/0.5 ML vial, 10 MG/0.5 ML vial, 12.5 MG/0.5 ML vial, 15 MG/0.5 ML vial — 4 Vials per 28 days
  • 2.5 MG/0.5 ML autoinjector — 4 Pens per 180 days (84-day)
  • 5 MG/0.5 ML autoinjector, 7.5 MG/0.5 ML autoinjector, 10 MG/0.5 ML autoinjector, 12.5 MG/0.5 ML autoinjector, 15 MG/0.5 ML autoinjector — 4 Pens per 28 days
  • 2.5 MG/0.6 ML KwikPen — 1 Pen per 180 days (84-day)
  • 5 MG/0.6 ML KwikPen, 7.5 MG/0.6 ML KwikPen, 10 MG/0.6 ML KwikPen, 12.5 MG/0.6 ML KwikPen, 15 MG/0.6 ML KwikPen — 1 Pen per 28 days

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, For renewal (after 52 weeks on maximum-tolerated dose), patient must have achieved and maintained >= 5% weight loss from baseline. Patients with < 52 weeks on maximum-tolerated dose may also qualify without demonstrating weight loss. Renewal also requires: obesity not restricted from benefit, continuing current weight loss course of therapy, pediatric patients (12-17) must have current BMI >= 85th percentile for age and sex, not combining with another weight loss agent, maintaining low-calorie diet/increased physical activity/behavioral modifications, not combining with another GLP-1 agonist, and no FDA labeled contraindications, and at least 52 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

  • Combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical) not allowed
  • Combination with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) not allowed
  • Any FDA labeled contraindications to the requested agent
  • Obesity restricted from coverage under the patient's benefit

Policy note: Zepbound available as vials, autoinjectors, and KwikPens — all covered. For continuation after 52 weeks on maximum-tolerated dose, patient must demonstrate >= 5% weight loss from baseline. Patients with < 52 weeks on maximum-tolerated dose may qualify for renewal without demonstrating weight loss. Policy also allows approval if patient has another FDA labeled indication for the requested agent. This weight_loss entry excludes the OSA pathway, which is captured separately.

Policy effective June 1, 2026 · verified June 4, 2026 · source: WY_Weight_Management_PAQL_ProgSum.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 12 and older
  • BMI of 30 or higher
  • BMI of 27 or higher with a weight-related condition (hypertension, T2DM, OSA, CVD, and dyslipidemia)
  • BMI of 25 or higher for patients of Asian descent
  • BMI at or above the 95th percentile for age and sex
  • 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Adult weight management (BMI >= 30)

All of:

  • Patient is an adult (18 years of age or over)
  • BMI >= 30 kg/m^2
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • Patient has NOT tried a targeted weight loss agent (e.g., Saxenda, Wegovy, Zepbound) in the past 12 months
  • Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy

Adult weight management (BMI >= 25 - Asian descent)

All of:

  • Patient is an adult (18 years of age or over)
  • Patient is of South Asian, Southeast Asian, or East Asian descent
  • BMI >= 25 kg/m^2
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • Patient has NOT tried a targeted weight loss agent in the past 12 months
  • Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy

Adult weight management (BMI >= 27 with comorbidity)

All of:

  • Patient is an adult (18 years of age or over)
  • BMI >= 27 kg/m^2
  • At least one weight-related comorbidity/risk factor/complication (e.g., hypertension, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, dyslipidemia)
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • Patient has NOT tried a targeted weight loss agent in the past 12 months
  • Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy

Pediatric weight management (age 12-17)

All of:

  • Patient is pediatric (12 to 17 years of age)
  • Obesity is NOT restricted from coverage under the patient's benefit
  • Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
  • Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
  • Patient will NOT use the requested agent in combination with another weight loss agent
  • Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
  • Age is within FDA labeling for the requested indication OR there is support for use at patient's age

Plus any one of:

  • BMI >= 95th percentile for age and sex
  • BMI >= 30 kg/m^2
  • BMI >= 85th percentile for age and sex AND at least one weight-related comorbidity/risk factor/complication (e.g., hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea)

Documentation to bring

  • Documentation of BMI >= 30 kg/m^2 (or >= 27 with comorbidity, or >= 25 if Asian descent, or BMI percentile for pediatric patients)
  • Documentation of 6-month weight loss regimen (low-calorie diet, increased physical activity, behavioral modifications)
  • Documentation of weight-related comorbidity if using the 27 kg/m^2 threshold
  • Documentation of ancestry if using the 25 kg/m^2 Asian threshold
  • Documentation that obesity is not restricted from coverage under the patient's benefit

Quantity limits

  • 2.5 MG/0.5 ML vial — 4 Vials per 180 days (84-day)
  • 5 MG/0.5 ML vial, 7.5 MG/0.5 ML vial, 10 MG/0.5 ML vial, 12.5 MG/0.5 ML vial, 15 MG/0.5 ML vial — 4 Vials per 28 days
  • 2.5 MG/0.5 ML autoinjector — 4 Pens per 180 days (84-day)
  • 5 MG/0.5 ML autoinjector, 7.5 MG/0.5 ML autoinjector, 10 MG/0.5 ML autoinjector, 12.5 MG/0.5 ML autoinjector, 15 MG/0.5 ML autoinjector — 4 Pens per 28 days
  • 2.5 MG/0.6 ML KwikPen — 1 Pen per 180 days (84-day)
  • 5 MG/0.6 ML KwikPen, 7.5 MG/0.6 ML KwikPen, 10 MG/0.6 ML KwikPen, 12.5 MG/0.6 ML KwikPen, 15 MG/0.6 ML KwikPen — 1 Pen per 28 days

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, For renewal (after 52 weeks on maximum-tolerated dose), patient must have achieved and maintained >= 5% weight loss from baseline. Patients with < 52 weeks on maximum-tolerated dose may also qualify without demonstrating weight loss. Renewal also requires: obesity not restricted from benefit, continuing current weight loss course of therapy, pediatric patients (12-17) must have current BMI >= 85th percentile for age and sex, not combining with another weight loss agent, maintaining low-calorie diet/increased physical activity/behavioral modifications, not combining with another GLP-1 agonist, and no FDA labeled contraindications, and at least 52 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

  • Combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical) not allowed
  • Combination with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) not allowed
  • Any FDA labeled contraindications to the requested agent
  • Obesity restricted from coverage under the patient's benefit

Policy note: Zepbound available as vials, autoinjectors, and KwikPens — all covered. For continuation after 52 weeks on maximum-tolerated dose, patient must demonstrate >= 5% weight loss from baseline. Patients with < 52 weeks on maximum-tolerated dose may qualify for renewal without demonstrating weight loss. Policy also allows approval if patient has another FDA labeled indication for the requested agent. This weight_loss entry excludes the OSA pathway, which is captured separately.

Policy effective June 1, 2026 · verified June 4, 2026 · source: WY_Weight_Management_PAQL_ProgSum.pdf

All Zepbound policies under BCBS Wyoming · Check your card