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Highmark · Weight Loss

Highmark coverage for Zepbound (Weight Loss)

Employer / Commercial Insurance

Depends on your plan's benefit

Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Zepbound is the plan-preferred agent for weight loss among this drug class.

What you need to qualify

  • Age 18 and older
  • BMI of 40 or higher
  • Diagnosis documented with a code (E66.0, E66.3)
  • 6 months of a documented diet and exercise program
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Adult Initiation (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • 0 to < 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member has one of the following clinical manifestations of organ dysfunction directly caused by obesity: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member has at least two of the following clinical manifestations of organ dysfunction directly caused by obesity: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Adult Maintenance (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Current height, weight, and BMI documented
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9) - re-verified
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of continued dietary changes and physical activity
  • Member has experienced and maintained >= 7.5% weight loss from baseline
  • Requested dose is 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly
  • >= 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member had one of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member had at least two of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 40 kg/m2)
  • For qualifying via metabolic pathway: lab results within 6 months showing prediabetes (A1C 5.7-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women)
  • For qualifying via organ dysfunction pathway: clinical documentation of qualifying comorbidity (coronary artery disease, MASH F2-F3, MI, stroke, PAD, peripheral vascular disease, or moderate-to-severe OSA) OR at least two qualifying comorbidities from the secondary list
  • Prescriber attestation that member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: current height, weight, and BMI
  • For maintenance: documentation of >= 7.5% weight loss from baseline
  • For maintenance: documentation or attestation that requested dose is a maintenance dose (5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly) or titrating to 5 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 7.5% weight loss from the starting weight, For adult maintenance (Section IV): member must have experienced and maintained >= 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Qualifying comorbidity (prediabetes+labs, or organ dysfunction) at baseline is re-verified at continuation. Maintenance dose requirements: Zepbound 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly, and staying on a maintenance dose of at least 5 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Type 2 diabetes mellitus (ICD-10: E11.9) — prescriber must attest member does NOT have T2DM diagnosis
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • Zepbound single-dose vials are only available for self-pay patients with an on-label prescription; vials cannot be billed through insurance coverage
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Delaware Commercial fully-insured and Healthcare Reform members without the anti-obesity benefit may access Zepbound coverage only for OSA (Section VI), not for weight loss under Section IV.

Policy note: Zepbound is the plan-preferred agent for weight loss in the GLP-1/GIP class. The adult weight loss criteria require BMI >= 40 with a qualifying comorbidity — this is substantially higher than FDA label thresholds (>= 27 with comorbidity or >= 30 without). There is no adolescent pathway for Zepbound under weight loss (adolescent weight loss only covers Saxenda and Wegovy injection, per Section III). The 2.5 mg dose is for initiation only and is not a maintenance dose. If pancreatitis occurs, member should not switch to another GLP-1 agent. Members established on samples or out-of-pocket will only be granted continuation if policy criteria are met. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

ACA Marketplace

Depends on your plan's benefit

Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Zepbound is the plan-preferred agent for weight loss among this drug class.

What you need to qualify

  • Age 18 and older
  • BMI of 40 or higher
  • Diagnosis documented with a code (E66.0, E66.3)
  • 6 months of a documented diet and exercise program
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Adult Initiation (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • 0 to < 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member has one of the following clinical manifestations of organ dysfunction directly caused by obesity: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member has at least two of the following clinical manifestations of organ dysfunction directly caused by obesity: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Adult Maintenance (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Current height, weight, and BMI documented
  • Baseline BMI >= 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9) - re-verified
  • Member will not use Zepbound in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of continued dietary changes and physical activity
  • Member has experienced and maintained >= 7.5% weight loss from baseline
  • Requested dose is 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly
  • >= 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member had one of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member had at least two of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must demonstrate BMI >= 40 kg/m2)
  • For qualifying via metabolic pathway: lab results within 6 months showing prediabetes (A1C 5.7-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides >= 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women)
  • For qualifying via organ dysfunction pathway: clinical documentation of qualifying comorbidity (coronary artery disease, MASH F2-F3, MI, stroke, PAD, peripheral vascular disease, or moderate-to-severe OSA) OR at least two qualifying comorbidities from the secondary list
  • Prescriber attestation that member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Prescriber attestation that member will not use Zepbound in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: current height, weight, and BMI
  • For maintenance: documentation of >= 7.5% weight loss from baseline
  • For maintenance: documentation or attestation that requested dose is a maintenance dose (5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly) or titrating to 5 mg once weekly

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • To renew, the plan looks for at least 7.5% weight loss from the starting weight, For adult maintenance (Section IV): member must have experienced and maintained >= 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Qualifying comorbidity (prediabetes+labs, or organ dysfunction) at baseline is re-verified at continuation. Maintenance dose requirements: Zepbound 5 mg, 7.5 mg, 10 mg, 12.5 mg, or 15 mg once weekly, or prescriber attests titrating to 5 mg once weekly, and staying on a maintenance dose of at least 5 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Type 2 diabetes mellitus (ICD-10: E11.9) — prescriber must attest member does NOT have T2DM diagnosis
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • Zepbound single-dose vials are only available for self-pay patients with an on-label prescription; vials cannot be billed through insurance coverage
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to tirzepatide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Delaware Commercial fully-insured and Healthcare Reform members without the anti-obesity benefit may access Zepbound coverage only for OSA (Section VI), not for weight loss under Section IV.

Policy note: Zepbound is the plan-preferred agent for weight loss in the GLP-1/GIP class. The adult weight loss criteria require BMI >= 40 with a qualifying comorbidity — this is substantially higher than FDA label thresholds (>= 27 with comorbidity or >= 30 without). There is no adolescent pathway for Zepbound under weight loss (adolescent weight loss only covers Saxenda and Wegovy injection, per Section III). The 2.5 mg dose is for initiation only and is not a maintenance dose. If pancreatitis occurs, member should not switch to another GLP-1 agent. Members established on samples or out-of-pocket will only be granted continuation if policy criteria are met. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J-1388-027.pdf

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