Premera coverage for Zepbound (Weight Loss)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Age 18 and older
BMI of 30 or higher
BMI of 27 or higher with a weight-related condition (Asthma, CVD, COPD, Coronary artery disease, Dyslipidemia, HTN, Knee osteoarthritis, MASH/NAFLD, OSA, PCOS, and T2DM)
3 months of a documented diet and exercise program

Qualification 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
To renew, the plan looks for at least 5% weight loss from the starting weight, 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, at least 28 weeks on therapy before the first renewal, and staying on a maintenance dose of at least 15 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

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.pdf