Applies to Federal Employee Program plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Initial Approval — BMI ≥ 30 (no comorbidity required)
All of:
- Age 18 or older
- BMI ≥ 30 kg/m²
- Inadequate treatment response, intolerance, or contraindication to at least TWO oral medications for weight management (e.g., benzphetamine, diethylpropion, phentermine, Qsymia)
- Patient has participated in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- No dual therapy with other GLP-1 receptor agonists
- No dual therapy with another PA medication for weight loss
- Must have tried the preferred product(s) unless valid medical exception (inadequate response, intolerance, or contraindication)
Initial Approval — BMI ≥ 27 with qualifying comorbidity
All of:
- Age 18 or older
- BMI ≥ 27 kg/m²
- Inadequate treatment response, intolerance, or contraindication to at least TWO oral medications for weight management (e.g., benzphetamine, diethylpropion, phentermine, Qsymia)
- Patient has participated in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- No dual therapy with other GLP-1 receptor agonists
- No dual therapy with another PA medication for weight loss
- Must have tried the preferred product(s) unless valid medical exception (inadequate response, intolerance, or contraindication)
Plus any one of:
- Established cardiovascular disease (congenital heart disease, cerebrovascular disease, peripheral artery disease, coronary heart disease, ACS, MI, unstable angina, coronary or other arterial revascularization, prior PCI/CABG)
- At least one weight-related comorbid condition (type 2 diabetes mellitus, dyslipidemia, or hypertension)
Renewal/Continuation
All of:
- Age 18 or older
- Chronic weight management indication
- No dual therapy with other GLP-1 receptor agonists
- No dual therapy with another PA medication for weight loss
- Patient has participated in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- Must have tried the preferred product(s) unless valid medical exception
Plus any one of:
- Patient has lost at least 5% of baseline body weight
- Patient has continued to maintain their initial 5% weight loss
Documentation to bring
- Medical records or laboratory reports documenting BMI (≥ 30 kg/m² or ≥ 27 kg/m² with qualifying comorbidity)
- Documentation of inadequate treatment response, intolerance, or contraindication to at least two oral weight management medications (e.g., benzphetamine, diethylpropion, phentermine, Qsymia)
- Documentation of participation in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- Documentation of qualifying cardiovascular disease or weight-related comorbid condition if BMI is 27–29 kg/m²
- Documentation that patient is not on dual therapy with another GLP-1 receptor agonist
- Documentation that patient is not on dual therapy with another PA-required weight loss medication
- Documentation of prior trial of preferred product(s) or valid medical exception (inadequate response, intolerance, or contraindication)
- For renewal: documentation of at least 5% baseline body weight loss or maintenance of initial 5% weight loss
Quantity limits
- 2.5mg, 5mg, 7.5mg, 10mg, 12.5mg, 15mg — 12 single-dose pens per 84 days (84-day)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- Renewal: Patient must have lost at least 5% of baseline body weight OR maintained their initial 5% weight loss. Comprehensive weight management program participation also required at renewal. BMI threshold, prior oral weight loss medication trial, and preferred product step therapy are not explicitly re-verified at continuation.
Not covered when
- Dual therapy with other GLP-1 receptor agonists (Trulicity, Byetta, Bydureon, Bydureon BCise, Saxenda, Victoza, Xultophy, Adlyxin, Soliqua, Ozempic, Rybelsus, Wegovy, Mounjaro)
- Dual therapy with another PA weight loss medication
- Coadministration with other tirzepatide-containing products
- Patients under 18 years of age (safety and effectiveness not established)
- Patients with personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) — FDA contraindication
Policy note: Zepbound is noted as a non-preferred product on MedEx formulary (added January 2024). Preferred products are referenced via an external URL (FEP ProductMedChx.pdf / fepblue.org) rather than listed in the policy document itself. Policy was approved by the FEP Pharmacy and Medical Policy Committee on December 12, 2025. BMI must be evaluated after 12–16 weeks of treatment; if no appropriate decrease, medication should be discontinued. The OSA indication is referenced in the FDA-approved indications/regulatory section but NO separate PA criteria are established for OSA in this policy document — only weight management criteria are stated. At least two prior oral weight loss medications are required (policy says 'at least TWO'), which is more stringent than typical policies requiring one. Quantity limit applies to all strengths collectively (12 single-dose pens per 84 days); individual strength breakdowns are not differentiated in the policy.
Policy effective January 1, 2026 · verified June 5, 2026 · source: 599031 Zepbound Tirzepatide · View policy document (PDF)