Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Weight Loss — Initial Approval: Adult (age ≥ 18)
All of:
- Age ≥ 18 years
- Actively enrolled in an exercise and caloric reduction program
- No concurrent use of another GLP-1 receptor agonist or GLP-1/GIP receptor agonist
Plus any one of:
- BMI ≥ 30 kg/m² (general population)
- BMI ≥ 27.5 kg/m² (Asian patients)
- BMI ≥ 27 kg/m² AND at least one weight-related comorbidity (HTN, T2DM, dyslipidemia, CVD, CAD, sleep apnea, osteoarthritis of knees, PCOS, NASH/NAFLD, asthma, or COPD) (general population)
- BMI ≥ 25 kg/m² AND at least one weight-related comorbidity (Asian patients)
Weight Loss — Initial Approval: Adolescent (age 12–17)
All of:
- Age 12 to 17 years
- Initial BMI ≥ 95th percentile for age and sex
- Actively enrolled in an exercise and caloric reduction program
- No concurrent use of another GLP-1 receptor agonist or GLP-1/GIP receptor agonist
Weight Loss — Renewal: Adult (age ≥ 18)
All of:
- No concurrent use of another GLP-1 receptor agonist or GLP-1/GIP receptor agonist
- Baseline BMI eligibility re-confirmed (same thresholds as initial criteria)
- Achieved or maintained at least 5% weight loss of baseline body weight
Weight Loss — Renewal: Adolescent (age 12–17)
All of:
- Age 12 to 17 years
- No concurrent use of another GLP-1 receptor agonist or GLP-1/GIP receptor agonist
- Achieved or maintained at least 5% reduction of baseline BMI
Documentation to bring
- Documentation of patient age
- Baseline BMI documentation: ≥ 30 kg/m² (general adult), or ≥ 27.5 kg/m² (Asian adult), or ≥ 27 kg/m² with qualifying comorbidity (general adult), or ≥ 25 kg/m² with qualifying comorbidity (Asian adult), or ≥ 95th percentile for age/sex (adolescents 12–17)
- Documentation of at least one weight-related comorbidity if using lower BMI threshold (HTN, T2DM, dyslipidemia, CVD, CAD, sleep apnea, osteoarthritis of knees, PCOS, NASH/NAFLD, asthma, or COPD)
- Attestation of active enrollment in an exercise and caloric reduction program
- Confirmation of no concurrent GLP-1 receptor agonist or GLP-1/GIP receptor agonist use
- For renewal: documentation of ≥ 5% weight loss from baseline body weight (adults) or ≥ 5% BMI reduction from baseline (adolescents 12–17)
Approval and renewal
- Renewal: At least 5% reduction in BMI.
- Renewal: Renewal requires: (1) no concurrent GLP-1 or GLP-1/GIP agonist; (2) for adults (≥18): re-verification of baseline BMI eligibility criteria AND at least 5% weight loss of baseline body weight achieved or maintained; (3) for adolescents (12–17): at least 5% reduction of baseline BMI achieved or maintained. Note: the 5% threshold for adults is 5% of baseline body weight; for adolescents it is 5% of baseline BMI. Active lifestyle program enrollment is NOT explicitly re-verified at renewal.
Not covered when
- Concurrent use of another GLP-1 receptor agonist (liraglutide, exenatide, semaglutide other products) or GLP-1/GIP receptor agonist (tirzepatide products)
Policy note: The weight loss indication covers both adults (age ≥ 18) and adolescents (age 12–17). For Asian adults, BMI min asian = 27.5 kg/m² (no comorbidity required) or 25 kg/m² with comorbidity. For renewal, adults must re-verify both BMI eligibility AND 5% weight loss; adolescents only need 5% BMI reduction. The continuation weight loss percent (5%) and continuation BMI reduction percent (5%) reflect different metrics: 5% body weight for adults, 5% of baseline BMI for adolescents. Pregnancy/Type 1 diabetes/bariatric surgery exclusions are not explicitly stated in this document but are standard; marked false here since not explicitly documented.
Policy effective June 1, 2026 · verified June 5, 2026 · source: Standard Commercial Guidelines 6 1 26 Excerpted · View policy document (PDF)