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Kaiser Permanente Mid-Atlantic · Weight Loss

Kaiser Permanente Mid-Atlantic coverage for Zepbound (Weight Loss)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • BMI of 27 or higher with a weight-related condition (CVD, stroke, HTN, T2DM, CKD, CHD, PCOS, dyslipidemia, MASH, MASLD, idiopathic intracranial hypertension, and osteoarthritis in weight-bearing joints)
  • 3 months of a documented diet and exercise program
  • Prior trial of another GLP-1 medication (semaglutide (for overweight or obesity)) for at least 90 days
  • Prior trial of phentermine, diethylpropion, phentermine/topiramate (generic), Qsymia, naltrexone/bupropion (generic), and Contrave for at least 3 months

Qualification pathways

You can qualify through any one of these.

Zepbound for weight loss — BMI 27 to <30 with comorbidity (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 27 to <30 kg/m2
  • At least ONE qualifying weight-related comorbidity
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI 30 to <35 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 30 to <35 kg/m2
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI 35 to <40 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 35 to <40 kg/m2
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI >=40 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Currently enrolled in and/or following a lifestyle intervention program (to begin at or before medication initiation) and will continue lifestyle modifications
  • Baseline BMI >=40 kg/m2
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Documentation to bring

  • Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is an Endocrinologist, Pediatrician, or Weight Management Specialist
  • Patient age documentation (>=18 years)
  • Documented baseline weight within past 30 days
  • Documented baseline BMI
  • Documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Detailed diet and exercise log for past 90-180 days (lifestyle interventions with nutrition and physical activity components)
  • For BMI 27 to <30: documentation of at least one qualifying weight-related comorbidity
  • For BMI 27 to <35: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documentation that Zepbound is not being used in combination with another GLP-1 RA or GIP/GLP-1 RA

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight and Documented weight loss of at least 5% from baseline weight within the previous 6 months. Must continue prescriber-documented lifestyle interventions. If BMI is 25 to <27: 3-month x 1 reauthorization only (for deprescribing). If BMI >=27: 6-month reauthorization. Prior semaglutide step therapy and prior oral weight loss drug step therapy are NOT re-verified at continuation for existing members. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Combination use with another GIP/GLP-1 RA or GLP-1 RA not permitted

Policy note: Zepbound for weight loss requires prior documented failure/intolerance/contraindication to semaglutide for overweight or obesity (3-month trial at maximum tolerated dose) — this is a GLP-1 RA step-therapy requirement specific to Zepbound. Lifestyle documentation requirement is more specific than Wegovy: detailed diet and exercise log for past 90-180 days required. Age minimum is 18 (vs 12 for Saxenda/Wegovy). The BMI tier criteria from the general weight management section apply to Zepbound as they do to Wegovy and Saxenda, with the additional semaglutide step-therapy layer. Prior oral weight management drug step therapy applies to BMI 27 to <35 tiers.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • BMI of 27 or higher with a weight-related condition (CVD, stroke, HTN, T2DM, CKD, CHD, PCOS, dyslipidemia, MASH, MASLD, idiopathic intracranial hypertension, and osteoarthritis in weight-bearing joints)
  • 3 months of a documented diet and exercise program
  • Prior trial of another GLP-1 medication (semaglutide (for overweight or obesity)) for at least 90 days
  • Prior trial of phentermine, diethylpropion, phentermine/topiramate (generic), Qsymia, naltrexone/bupropion (generic), and Contrave for at least 3 months

Qualification pathways

You can qualify through any one of these.

Zepbound for weight loss — BMI 27 to <30 with comorbidity (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 27 to <30 kg/m2
  • At least ONE qualifying weight-related comorbidity
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI 30 to <35 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 30 to <35 kg/m2
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI 35 to <40 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 35 to <40 kg/m2
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI >=40 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Currently enrolled in and/or following a lifestyle intervention program (to begin at or before medication initiation) and will continue lifestyle modifications
  • Baseline BMI >=40 kg/m2
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Documentation to bring

  • Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is an Endocrinologist, Pediatrician, or Weight Management Specialist
  • Patient age documentation (>=18 years)
  • Documented baseline weight within past 30 days
  • Documented baseline BMI
  • Documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Detailed diet and exercise log for past 90-180 days (lifestyle interventions with nutrition and physical activity components)
  • For BMI 27 to <30: documentation of at least one qualifying weight-related comorbidity
  • For BMI 27 to <35: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documentation that Zepbound is not being used in combination with another GLP-1 RA or GIP/GLP-1 RA

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight and Documented weight loss of at least 5% from baseline weight within the previous 6 months. Must continue prescriber-documented lifestyle interventions. If BMI is 25 to <27: 3-month x 1 reauthorization only (for deprescribing). If BMI >=27: 6-month reauthorization. Prior semaglutide step therapy and prior oral weight loss drug step therapy are NOT re-verified at continuation for existing members. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Combination use with another GIP/GLP-1 RA or GLP-1 RA not permitted

Policy note: Zepbound for weight loss requires prior documented failure/intolerance/contraindication to semaglutide for overweight or obesity (3-month trial at maximum tolerated dose) — this is a GLP-1 RA step-therapy requirement specific to Zepbound. Lifestyle documentation requirement is more specific than Wegovy: detailed diet and exercise log for past 90-180 days required. Age minimum is 18 (vs 12 for Saxenda/Wegovy). The BMI tier criteria from the general weight management section apply to Zepbound as they do to Wegovy and Saxenda, with the additional semaglutide step-therapy layer. Prior oral weight management drug step therapy applies to BMI 27 to <35 tiers.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

Federal Employee Program

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • BMI of 27 or higher with a weight-related condition (CVD, stroke, HTN, T2DM, CKD, CHD, PCOS, dyslipidemia, MASH, MASLD, idiopathic intracranial hypertension, and osteoarthritis in weight-bearing joints)
  • 3 months of a documented diet and exercise program
  • Prior trial of another GLP-1 medication (semaglutide (for overweight or obesity)) for at least 90 days
  • Prior trial of phentermine, diethylpropion, phentermine/topiramate (generic), Qsymia, naltrexone/bupropion (generic), and Contrave for at least 3 months

Qualification pathways

You can qualify through any one of these.

Zepbound for weight loss — BMI 27 to <30 with comorbidity (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 27 to <30 kg/m2
  • At least ONE qualifying weight-related comorbidity
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI 30 to <35 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 30 to <35 kg/m2
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI 35 to <40 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Actively adhering to prescriber-documented lifestyle interventions (detailed diet and exercise log for past 90-180 days) and will continue lifestyle modifications
  • Baseline BMI 35 to <40 kg/m2
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Zepbound for weight loss — BMI >=40 (after semaglutide step therapy)

All of:

  • Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
  • Age >= 18 years
  • Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Currently enrolled in and/or following a lifestyle intervention program (to begin at or before medication initiation) and will continue lifestyle modifications
  • Baseline BMI >=40 kg/m2
  • Documented baseline weight within past 30 days
  • Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA

Documentation to bring

  • Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is an Endocrinologist, Pediatrician, or Weight Management Specialist
  • Patient age documentation (>=18 years)
  • Documented baseline weight within past 30 days
  • Documented baseline BMI
  • Documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial at maximum tolerated dose of semaglutide for overweight or obesity
  • Detailed diet and exercise log for past 90-180 days (lifestyle interventions with nutrition and physical activity components)
  • For BMI 27 to <30: documentation of at least one qualifying weight-related comorbidity
  • For BMI 27 to <35: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
  • Documentation that Zepbound is not being used in combination with another GLP-1 RA or GIP/GLP-1 RA

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 6 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight and Documented weight loss of at least 5% from baseline weight within the previous 6 months. Must continue prescriber-documented lifestyle interventions. If BMI is 25 to <27: 3-month x 1 reauthorization only (for deprescribing). If BMI >=27: 6-month reauthorization. Prior semaglutide step therapy and prior oral weight loss drug step therapy are NOT re-verified at continuation for existing members. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Combination use with another GIP/GLP-1 RA or GLP-1 RA not permitted

Policy note: Zepbound for weight loss requires prior documented failure/intolerance/contraindication to semaglutide for overweight or obesity (3-month trial at maximum tolerated dose) — this is a GLP-1 RA step-therapy requirement specific to Zepbound. Lifestyle documentation requirement is more specific than Wegovy: detailed diet and exercise log for past 90-180 days required. Age minimum is 18 (vs 12 for Saxenda/Wegovy). The BMI tier criteria from the general weight management section apply to Zepbound as they do to Wegovy and Saxenda, with the additional semaglutide step-therapy layer. Prior oral weight management drug step therapy applies to BMI 27 to <35 tiers.

Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf

All Zepbound policies under Kaiser Permanente Mid-Atlantic · Check your card