The facts
Weight loss
Plan-dependent
Type 2 diabetes
Not indicated
Prior auth
Required
Typical cost
Tier 2, if your plan includes the benefit
The criteria, as published
2 of 9 criteria are stated in the Anthem documents we read. Tap a row for the exact wording. Where a cell says not published, the documents we read do not say, and the line under it is how to find out.
- Formulary status
Tier 2 with PA, QL and benefit exclusion (BE) on the 2026 NY Essential 3-Tier list
“ANTI-OBESITY - GIP & GLP-1 RECEPTOR AGONISTS | ZEPBOUND SUBCUTANEOUS SOLUTION AUTO-INJECTOR | 2 | PA; BE; QL … WEGOVY SUBCUTANEOUS SOLUTION AUTO-INJECTOR | 2 | PA; BE; QL … WEGOVY ORAL TABLET | 2 | PA; BE; QL … SAXENDA SUBCUTANEOUS SOLUTION PEN-INJECTOR | 3 | PA; BE; QL”
fm.formularynavigator.com · 2026 plan year, New York Essential 3-Tier- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Zepbound.
- Qualifying conditions
- Not published in what we readAsk which conditions the Zepbound criteria accept alongside BMI.
- Lifestyle program
- Not published in what we readAsk whether a diet, exercise or behavioral program has to be documented, and for how long.
- Step therapy
- Not published in what we readAsk whether another drug has to be tried before Zepbound.
- Quantity limit
- Not published in what we readAsk what quantity limit applies to each fill.
- Renewal
- Not published in what we readAsk how long an approval lasts and what the renewal needs.
- Plan can exclude it?
Yes: BE means it may not be covered depending on your plan's design
“BE = benefit exclusion. This drug may not be covered depending on your plans design. To find out if your drug is covered, log into your member portal or use the Sydney app to Price a Medication and refer to your plan documents. … PA = prior authorization.”
fm.formularynavigator.com · 2026 plan year, drug list key- 2026 change
- Not published in what we readAsk whether Zepbound's status changed this year or changes at your next renewal.
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager
No single PBM to name here, which is itself the finding. Different plans under this name use different benefit managers, so one national statement about the formulary would be wrong.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
How prior authorization works here
Six steps. Specifics come from the criteria above; where Anthem does not publish one, the step says what to ask for.
- 1
Confirm the benefit exists
Before any paperwork, ask whether your plan includes the weight-loss drug benefit. On whether a plan can leave it out, the documents say: Yes: BE means it may not be covered depending on your plan's design.
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Zepbound, so your prescriber answers the plan's questions rather than guessing at them.
- 3
Your prescriber documents the clinical picture
Current and baseline BMI, with dates. Any weight-related conditions, with diagnosis codes. Records of any diet, exercise or behavioral program.
- 4
Answer step therapy, if there is any
Ask whether another drug must come first. If you have already tried one, the request should list it with dates and the reason it stopped.
- 5
Submit, then track it
Your prescriber sends the plan’s form with the notes. Our Zepbound prior authorization letter template covers the cover letter. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
Ask how long the approval lasts and what the renewal needs, so the gap does not catch you out.
Get your real answer
Price Zepbound in your member portal or the Sydney app rather than relying on the published drug list, because the benefit-exclusion flag means the list cannot answer for your plan. If it is covered, the prior authorisation is the next step and a documented BMI, comorbidity and lifestyle history is what it turns on.
Coverage is plan-specific: this page reports what Anthem publishes, not a promise about your plan. Not medical or insurance advice.
