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, and CVD)
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Initial Approval - BMI ≥30 without comorbidity
All of:
- Age 18 years or older
- BMI ≥ 30 kg/m² documented within 90 days of request
- Tried but was unsuccessful losing weight through HCP-supervised comprehensive lifestyle program for at least 6 months including calorie deficit ~30%/500 kcals/day AND ≥150 min/week exercise (or clinical exception) AND failed to achieve ≥5% weight reduction
- Currently maintained on HCP-supervised lifestyle program with calorie deficit ~30%/500 kcals/day AND ≥150 min/week exercise (or clinical exception)
- NOT receiving two or more medications for weight loss simultaneously
- HCP has counseled individual regarding risks, benefits, realistic expectations, long-term follow-up, and behavior modification adherence
Initial Approval - BMI ≥27 with qualifying comorbidity
All of:
- Age 18 years or older
- BMI ≥ 27 kg/m² documented within 90 days of request
- Tried but was unsuccessful losing weight through HCP-supervised comprehensive lifestyle program for at least 6 months including calorie deficit ~30%/500 kcals/day AND ≥150 min/week exercise (or clinical exception) AND failed to achieve ≥5% weight reduction
- Currently maintained on HCP-supervised lifestyle program with calorie deficit ~30%/500 kcals/day AND ≥150 min/week exercise (or clinical exception)
- NOT receiving two or more medications for weight loss simultaneously
- HCP has counseled individual regarding risks, benefits, realistic expectations, long-term follow-up, and behavior modification adherence
Plus any one of:
- Hypertension: treated hypertension OR SBP ≥130 mmHg OR DBP ≥80 mmHg
- Type II Diabetes Mellitus
- Dyslipidemia: treated dyslipidemia OR LDL ≥160 mg/dL OR triglycerides ≥150 mg/dL OR HDL <40 mg/dL (men) OR HDL <50 mg/dL (women)
- Obstructive sleep apnea as a result of having a BMI of 27 or greater
- Cardiovascular disease (e.g., ischemic cardiovascular disease, NYHA Functional Class I-III heart failure)
Continuation Approval
All of:
- Age 18 years or older
- Documentation that at initiation of therapy individual had BMI ≥30 kg/m² OR BMI ≥27 kg/m² with a qualifying comorbidity (hypertension, T2DM, dyslipidemia, OSA, or CVD)
- Documentation of achieved/maintained ≥5% weight loss from initiation of therapy (required within 90 days of each continuation request)
- Continues to be engaged in comprehensive lifestyle program: calorie deficit ~30%/500 kcals/day AND ≥150 min/week exercise (or clinical exception)
- NOT receiving two or more medications for weight loss simultaneously
- HCP has counseled individual regarding risks, benefits, realistic expectations, long-term follow-up, and behavior modification adherence
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
- To renew, the plan looks for at least 5% weight loss from the starting weight and 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. Make sure your starting weight and date are in the chart now — renewal is measured against it.
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: Download