The facts
Weight loss
Generally no
Type 2 diabetes
Yes, with PA on Cigna plans (type 2 diabetes diagnosis)
Prior auth
Required on Cigna employer plans
Typical cost
Plan-specific
The criteria, as published
4 of 9 criteria are stated in the Express Scripts 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
Listed on the 2027 National Preferred Formulary (Ozempic and Ozempic tablets)
“OZEMPIC … OZEMPIC TABLETS … THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2027, THROUGH DECEMBER 31, 2027. THIS LIST IS SUBJECT TO CHANGE.”
express-scripts.com · 2027 plan year- BMI threshold
- Not published in what we readAsk member services for the written prior authorization criteria for Ozempic.
- Qualifying conditions
Type 2 diabetes diagnosis, with documentation (Cigna policy)
“Mounjaro, Ozempic injection, Ozempic tablets, Rybelsus and Trulicity are considered medically necessary … Type 2 Diabetes Mellitus. Approve for 1 year if the patient meets the following (A): A) Diagnosis of Type 2 diabetes mellitus [Documentation Required]”
static.cigna.com · 2026-06-15- 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 Ozempic.
- Quantity limit
- Not published in what we readAsk what quantity limit applies to each fill.
- Renewal
Approved 1 year at a time (Cigna policy)
“Mounjaro, Ozempic injection, Ozempic tablets, Rybelsus and Trulicity are considered medically necessary … Type 2 Diabetes Mellitus. Approve for 1 year if the patient meets the following (A): A) Diagnosis of Type 2 diabetes mellitus [Documentation Required]”
static.cigna.com · 2026-06-15- Plan can exclude it?
Weight loss without type 2 diabetes is not a covered use (Cigna policy)
“The GLP-1 agonists and GLP-1/glucose-dependent insulinotropic polypeptide-1 agonist in this policy are not FDA-approved for weight loss in a patient who is overweight (body mass index [BMI] ≥ 27 kg/m2) or obese (BMI ≥ 30 kg/m2) without type 2 diabetes.”
static.cigna.com · 2026-06-15- 2026 change
- Not published in what we readAsk whether Ozempic'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 · Express Scripts
This page is about the benefit manager itself. Express Scripts builds the formularies, so what is preferred, excluded or subject to step therapy on them is its decision. Which of its formularies you get, and whether weight-loss drugs are on your plan at all, is your plan sponsor’s choice. Insurers we cover that run on Express Scripts: Cigna.
- 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 Express Scripts 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: Weight loss without type 2 diabetes is not a covered use (Cigna policy).
- 2
Get the criteria in writing
Ask for the written prior authorization criteria for Ozempic, 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. Conditions: Type 2 diabetes diagnosis, with documentation (Cigna policy). 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. Write down the date and the reference number, and ask how you will hear back.
- 6
Plan for the renewal
What the documents say: Approved 1 year at a time (Cigna policy).
Get your real answer
If you have type 2 diabetes, ask your prescriber to send the diagnosis with the prescription and file prior authorization through esrx.com/PA. Check your copay at express-scripts.com or the number on your ID card.
Coverage is plan-specific: this page reports what Express Scripts publishes, not a promise about your plan. Not medical or insurance advice.
