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 (HTN, T2DM, dyslipidemia, OSA, CVD, knee_osteoarthritis, asthma, COPD, MASLD/NAFLD, PCOS, and CAD)
- 3 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Initial Approval - Adult Weight Loss (BMI >= 30)
All of:
- Patient is >= 18 years of age
- Baseline BMI >= 30 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Initial Approval - Adult Weight Loss (BMI >= 27 with comorbidity)
All of:
- Patient is >= 18 years of age
- Baseline BMI >= 27 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Plus any one of:
- At baseline or currently: hypertension
- At baseline or currently: type 2 diabetes
- At baseline or currently: dyslipidemia
- At baseline or currently: obstructive sleep apnea
- At baseline or currently: cardiovascular disease
- At baseline or currently: knee osteoarthritis
- At baseline or currently: asthma
- At baseline or currently: COPD
- At baseline or currently: MASLD/NAFLD
- At baseline or currently: polycystic ovarian syndrome
- At baseline or currently: coronary artery disease
Continuation - Adult Weight Loss
All of:
- Patient is >= 18 years of age
- Baseline BMI >= 30 kg/m2 OR (BMI >= 27 kg/m2 with qualifying comorbidity) (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has lost >= 5% of baseline body weight
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Patient has completed >= 8 months of initial therapy
Documentation to bring
- Baseline BMI documentation (>= 30 kg/m2, or >= 27 kg/m2 with qualifying comorbidity, prior to any GLP-1 or GLP-1/GIP agonist)
- Documentation of at least 3-month trial of behavioral modification and dietary restriction (initial therapy)
- Documentation of qualifying weight-related comorbidity if baseline BMI 27-29.9 kg/m2
- Documentation of >= 5% baseline body weight loss (continuation)
Approval and renewal
- Initial approval: 8 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and Must have lost >= 5% of baseline body weight (baseline = prior to any GLP-1 or GLP-1/GIP agonist). Ongoing behavioral modification and reduced-calorie diet required. BMI threshold re-verified at continuation; 3-month lifestyle program not re-checked. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists is not covered
- Any use not meeting FDA-approved indications or criteria above is not medically necessary
Policy note: Zepbound weight loss indication is for adults only (age >= 18); no pediatric indication for weight loss. Initial approval is 8 months; continuation is 1 year. Baseline BMI is defined as prior to any GLP-1 or GLP-1/GIP agonist (not just prior to Zepbound).
Policy effective April 15, 2026 · verified June 2, 2026 · source: cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.pdf