The facts
Weight loss
Plan-dependent
Type 2 diabetes
Not indicated
Prior auth
Required
Typical cost
Plan-specific
The criteria, as published
4 of 9 criteria are stated in the Blue Cross Blue Shield 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
- Not published in what we readLook Zepbound up in your plan's drug list or price tool, or call the number on your card.
- BMI threshold
BMI 30+, or 27+ with a weight-related condition (FEP policy)
“Body mass index (BMI) ≥ 30 kg/m2 [or] Body mass index (BMI) ≥ 27 kg/m2 AND … at least one weight related comorbid condition”
fepblue.org · 2026-01-01- Qualifying conditions
At least one weight-related comorbid condition when BMI is 27 to 29.9
“Body mass index (BMI) ≥ 30 kg/m2 [or] Body mass index (BMI) ≥ 27 kg/m2 AND … at least one weight related comorbid condition”
fepblue.org · 2026-01-01- 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
Must fail two oral weight-loss drugs and try the preferred product(s) first (FEP)
“Inadequate treatment response, intolerance, or contraindication to at least TWO oral medications for weight management … Patient MUST have tried the preferred product(s) … unless the patient has a valid medical exception”
fepblue.org · 2026-01-01- 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: BCBS Michigan and BCN stopped covering GLP-1s for weight loss
“will no longer cover prescriptions for glucagon-like peptide-agonist drugs used for weight loss, including Saxenda, Wegovy and Zepbound”
providerinfo.bcbsm.com · 2024-09-27- 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 Blue Cross Blue Shield 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: BCBS Michigan and BCN stopped covering GLP-1s for weight loss.
- 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
BMI: BMI 30+, or 27+ with a weight-related condition (FEP policy). Conditions: At least one weight-related comorbid condition when BMI is 27 to 29.9. Records of any diet, exercise or behavioral program.
- 4
Answer step therapy, if there is any
What the documents say: Must fail two oral weight-loss drugs and try the preferred product(s) first (FEP). If you already tried that drug, or cannot take it, the request should say so with dates.
- 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
Ask your specific BCBS plan's member services whether Zepbound is on your 2026 formulary, and request the written prior-authorization criteria, specifically whether you must try Wegovy or Saxenda first (step therapy) and what BMI and documentation thresholds apply.
Coverage is plan-specific: this page reports what Blue Cross Blue Shield publishes, not a promise about your plan. Not medical or insurance advice.
