Employer / Commercial Insurance
Depends on your plan's benefitCoverage applies only when member's benefit covers weight loss drugs and requires prior authorization. Employer or plan must have weight loss drug benefit.
What you need to qualify
- Age 12 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (HTN, T2DM, dyslipidemia, OSA, and CVD)
- 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 initial approval - BMI >= 30
All of:
- Age >= 18 years
- BMI >= 30 kg/m2 documented within 90 days of request
- Trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction
- Currently maintained on healthcare provider supervised lifestyle program
- Not receiving two or more medications for weight loss simultaneously
- Healthcare provider consultation regarding risks, benefits, and realistic expectations
Adult initial approval - BMI >= 27 with weight-related comorbidity
All of:
- Age >= 18 years
- BMI >= 27 kg/m2 documented within 90 days of request
- Trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction
- Currently maintained on healthcare provider supervised lifestyle program
- Not receiving two or more medications for weight loss simultaneously
- Healthcare provider consultation regarding risks, benefits, and realistic expectations
Plus any one of:
- Hypertension (treated or SBP >= 130 mmHg or DBP >= 80 mmHg)
- Type II Diabetes Mellitus
- Dyslipidemia (treated or LDL >= 160 mg/dL or triglycerides >= 150 mg/dL or HDL <40 mg/dL [men] or <50 mg/dL [women])
- Obstructive sleep apnea (as a result of BMI >= 27)
- Cardiovascular disease (ischemic CVD or NYHA Class I-III heart failure)
Adolescent initial approval (ages 12-17)
All of:
- Age 12 to 17 years
- BMI >= 95th percentile for age and sex documented within 90 days of request
- Individual and caregiver utilized healthy nutrition and behavior counseling for >= 6 months with inadequate weight reduction
- Currently maintained on healthy nutrition and behavior counseling
- Not receiving two or more medications for weight loss simultaneously
- Healthcare provider consultation regarding risks, benefits, and realistic expectations
Documentation to bring
- Documentation of BMI >= 30 kg/m2 (adults) or BMI >= 95th percentile for age and sex (adolescents) within 90 days of request
- For adults with BMI 27-29: documentation of at least one weight-related comorbidity (HTN, T2DM, dyslipidemia, OSA from BMI >= 27, or CVD)
- Documentation of prior trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months (adults: including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction; adolescents: healthy nutrition and behavior counseling for >= 6 months with inadequate weight reduction)
- Documentation of current enrollment and maintenance in healthcare provider supervised lifestyle program
- Documentation that individual is NOT receiving two or more weight loss medications simultaneously
- Documentation of healthcare provider consultation regarding risks, benefits, realistic expectations, and need for long-term follow-up and behavior modification adherence
- For continuation (adults): Documentation of achieved/maintained >= 5% weight loss within 90 days of continuation request
- For continuation (adolescents): Documentation of achieved/maintained >4% reduction from baseline BMI within 90 days of continuation request
- For continuation: Documentation of continued engagement in comprehensive lifestyle program (adults) or healthy nutrition and behavior counseling (adolescents)
Quantity limits
- 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg, 7.2mg — Subject to quantity limit (specific limit not detailed in document)
Approval and renewal
- Initial approval: 7 months
- Renewal: every 6 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, at least 4% reduction in BMI, and Adults: Documentation of achieved/maintained initial 5% weight loss (required within 90 days of each continuation request). BMI eligibility criteria are re-verified based on BMI at initiation of therapy (not current BMI). Continued engagement in comprehensive lifestyle program required. Adolescents: Documentation of achieved/maintained >4% reduction from baseline BMI (required within 90 days of each continuation request). Continued healthy nutrition and behavior counseling required. Note: The 5% continuation threshold applies to adults; the 4% BMI reduction threshold applies to adolescents. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- BMI < 18.5 kg/m2
- Use for treatment of type 2 diabetes mellitus
- Personal or family history of medullary thyroid carcinoma (MTC)
- Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- History of pancreatitis
- Concurrent use of another semaglutide agent or any other GLP-1 agonist
- History of suicide attempts or active suicidal ideation
- Receiving two or more medications for weight loss simultaneously
Policy note: Initial approval duration is 28 weeks (approximately 7 months) for both adults and adolescents. Continuation approvals are 6 months. Adults use injection or tablets (0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg, 7.2 mg); adolescents use injection only (0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg). Coverage is conditioned on member's benefit covering weight loss drugs. Adult continuation re-verifies BMI eligibility using BMI at initiation of therapy (not current). Adolescent continuation requires >4% reduction from baseline BMI. Weight loss for treatment of T2DM is explicitly excluded (use for T2DM treatment is a denial reason). T1DM is not explicitly listed as a weight loss exclusion for adolescents, but is listed for adults in the adult exclusion section. Document references both a 7.2 mg strength for adults (not listed for adolescents). Dyslipidemia qualifying comorbidity is specifically defined with lab thresholds. OSA as comorbidity requires it to be 'as a result of having a BMI of 27 or greater.' Exercise exception allowed for clinical limitations including cardiovascular conditions, physical limitations, or fall risk.
Policy effective April 3, 2026 · verified June 2, 2026 · source: Download