Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 40 or higher
- BMI of 30 or higher with a weight-related condition (HTN, dyslipidemia, osteoarthritis, OSA, PCOS, and CVD)
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Standard obesity pathway (BMI >= 40 with comorbidities)
All of:
- BMI >= 40 kg/m2
- At least two obesity-related comorbidities (e.g., hypertension, high cholesterol, arthritis, sleep apnea, PCOS)
- In-person assessment and documentation of participation in an evidence-based lifestyle management program for 6 months
- Medical reason not to use Zepbound (Wegovy is non-preferred; Zepbound is preferred)
Cardiovascular disease pathway (BMI >= 30)
All of:
- BMI >= 30 kg/m2
- History of serious cardiovascular disease (e.g., stroke or heart attack)
- In-person assessment and documentation of participation in an evidence-based lifestyle management program for 6 months
- Medical reason not to use Zepbound (Wegovy is non-preferred; Zepbound is preferred)
Documentation to bring
- Baseline BMI documentation (>= 40 kg/m2 for standard pathway, or >= 30 kg/m2 for cardiovascular disease pathway)
- Documentation of at least two obesity-related comorbidities (if using standard BMI >= 40 pathway): e.g., hypertension, high cholesterol, arthritis, sleep apnea, PCOS
- Documentation of serious cardiovascular disease history (e.g., prior stroke or heart attack) if using BMI >= 30 pathway
- Documentation of in-person assessment and 6-month participation in an evidence-based lifestyle management program
- Documentation of medical reason why Zepbound cannot be used (required since Wegovy is non-preferred)
Policy note: Wegovy is non-preferred for weight loss; Zepbound is the preferred GLP-1. Wegovy is reserved for members with a medical reason not to use Zepbound. The BMI >= 30 threshold applies specifically to members with more serious cardiovascular disease such as history of stroke or heart attack. Applies to commercial plans only; Medicare Advantage, State program, and Self-funded members should check their plan documents. Detailed continuation criteria and quantity limits are not provided in this document.
source: Pa policy