FEP Blue coverage for Zepbound (Weight Loss)

Federal Employee Program

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
BMI of 27 or higher with a weight-related condition (CVD, T2DM, dyslipidemia, and HTN)
6 months of a documented diet and exercise program
Prior trial of benzphetamine, diethylpropion, phentermine, and Qsymia

Qualification 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
To renew, the plan looks for at least 5% weight loss from the starting weight and 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. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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.pdf