Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Adult weight management (18+) — BMI ≥ 30
All of:
- Age ≥ 18 years
- BMI ≥ 30 kg/m2
- Trial of behavioral modification and dietary restriction for at least 3 months
- Medication used as adjunct to reduced-calorie diet and increased physical activity
- Dose limited to 15 mg once weekly
- Quantity limited to 4 prefilled pens or single-dose vials per 28 days, OR 1 Kwikpen or multi-dose vial per 28 days
- Not used concurrently with other weight loss medications
Adult weight management (18+) — BMI ≥ 27 with comorbidity
All of:
- Age ≥ 18 years
- BMI ≥ 27 kg/m2
- Trial of behavioral modification and dietary restriction for at least 3 months
- Medication used as adjunct to reduced-calorie diet and increased physical activity
- Dose limited to 15 mg once weekly
- Quantity limited to 4 prefilled pens or single-dose vials per 28 days, OR 1 Kwikpen or multi-dose vial per 28 days
- Not used concurrently with other weight loss medications
Plus any one of:
- Asthma
- Cardiovascular disease
- COPD
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease/non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
Documentation to bring
- Office visit notes containing baseline body weight and BMI
- Documentation of relevant history including any weight-related comorbidities
- Documentation of dietary plan and physical activity plan
- Documentation of at least 3-month trial of behavioral modification and dietary restriction
- Medication dosage documentation
Quantity limits
- 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, 15 mg — 4 prefilled pens or single-dose vials per 28 days, OR 1 Kwikpen or multi-dose vial per 28 days
Approval and renewal
- Initial approval: 7 months
- Renewal: every 12 months
- Renewal: Adults: ≥5% baseline body weight loss after 7 months of treatment AND able to tolerate Zepbound maintenance dose of up to 15 mg once weekly AND continues adherence to reduced-calorie diet and increased physical activity. Non-formulary exception reviews may be approved up to 12 months.
- Renewal: At least 28 weeks on therapy before the first renewal.
- Renewal: Staying on a maintenance dose of at least 15 mg.
Not covered when
- Concurrent use with other weight loss medications (phentermine, phentermine/topiramate ER, benzphetamine, diethylpropion, phendimetrazine, Alli, Contrave, liraglutide 18 mg/3 mL pen, Qsymia, Saxenda, Xenical, Wegovy)
- All uses other than FDA-approved dosage and administration are considered investigational
- Coverage subject to benefit plan; many plans exclude weight management drugs
- This medical policy does not apply to Medicare Advantage
Policy note: No pediatric indication listed for Zepbound weight management in this policy (adults 18+ only). Quantity limit updated in 2026 to distinguish prefilled pens/single-dose vials (4 per 28 days) from Kwikpen/multi-dose vials (1 per 28 days).
Policy effective April 1, 2026 · verified June 3, 2026 · source: 5.01.621 · View policy document (PDF)