Does Elevance Health cover Zepbound?

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• BMI documentation ≥30 kg/m² OR ≥27 kg/m² with qualifying comorbidity, measured within 90 days of the initial request
• Documentation of qualifying weight-related comorbidity if BMI is 27–<30 (e.g., hypertension diagnosis/BP readings, T2DM diagnosis, dyslipidemia labs, OSA diagnosis, CVD diagnosis)
• Documentation of HCP-supervised comprehensive lifestyle program of at least 6 months including calorie deficit ~30%/500 kcals/day for at least 6 months
• Documentation of at least 150 minutes of exercise per week for at least 6 months OR documentation of clinical limitations preventing exercise
• Documentation of failure to achieve ≥5% weight reduction with lifestyle program
• Documentation that individual is currently maintained on HCP-supervised lifestyle program (calorie deficit and exercise or clinical exception)
• Documentation that individual is NOT receiving two or more weight loss medications simultaneously
• HCP attestation of risk/benefit counseling including adverse drug events, realistic expectations, long-term follow-up, and behavior modification
• For continuation: documentation of ≥5% weight loss achieved/maintained from therapy initiation, within 90 days of each continuation request

Quantity limits

• all strengths — May be subject to quantity limit (specific limits not detailed in document)

Approval and renewal

• Renewal: every 6 months
• Renewal: Documentation of at least 5% weight loss achieved/maintained from initiation of therapy (required within 90 days of each continuation/subsequent request). Individual must continue engagement in comprehensive lifestyle program (calorie deficit ~30%/500 kcals/day and ≥150 min/week exercise or documented clinical exception). Individual must not be receiving two or more weight loss medications simultaneously. HCP must continue risk/benefit counseling. BMI criteria are verified against initiation-of-therapy documentation, not re-measured at continuation.

Not covered when

• BMI less than 18.5 kg/m²
• Use for treatment of type 2 diabetes mellitus
• Use in combination with another tirzepatide-containing product or any GLP-1 receptor agonist
• Personal or family history of medullary thyroid carcinoma (MTC)
• Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
• History of pancreatitis
• Severe gastrointestinal disease (including but not limited to gastroparesis)
• History of suicide attempts or active suicidal ideation

Policy note: Initial approval duration is 32 weeks (approximately 7.5 months), not a standard round number. Continuation approvals are 6 months. The document references pediatric BMI tables (ages 12–17.5) but the approval criteria explicitly state age ≥18; the pediatric tables appear to be reference material carried over from a broader policy template and do not establish pediatric criteria for Zepbound under this document. Dyslipidemia comorbidity is defined with specific lab thresholds (LDL ≥160, TG ≥150, HDL <40 men or <50 women). OSA as a comorbidity is specifically qualified as being 'as a result of having a BMI of 27 or greater.' CVD examples include ischemic cardiovascular disease and NYHA Class I-III heart failure. The lifestyle program requirement is a formal 6-month HCP-supervised program — not merely standard diet and exercise counseling — including specific calorie deficit and exercise targets with documented outcomes.

Policy effective February 1, 2026 · verified June 2, 2026 · source: Elevance Health ACA Marketplace prior authorization policy · View policy document (PDF)