The facts
Weight loss
Plan-dependent
Type 2 diabetes
Not indicated
Prior auth
Required on Cigna-administered plans
Typical cost
No more than $200 a month, only if your employer adds Evernorth's capped-copay option
The criteria, as published
7 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
Zepbound pens preferred on the 2026 National Preferred Formulary; Zepbound KwikPens and vials excluded
“Weight Loss … ZEPBOUND KWIKPENS, ZEPBOUND VIALS … liraglutide, FOUNDAYO, WEGOVY HD, WEGOVY PENS, WEGOVY TABLETS, ZEPBOUND PENS”
express-scripts.com · 2026-10-01- BMI threshold
BMI 30+, or 27+ with a weight-related condition (Cigna policy)
“a) At baseline, patient had a BMI ≥ 30 kg/m2; OR … (1)At baseline, patient had a BMI ≥ 27 kg/m2; AND”
static.cigna.com · 2026-09-01- Qualifying conditions
Hypertension, type 2 diabetes, high cholesterol, sleep apnea, heart disease, knee arthritis, asthma, COPD, fatty liver disease, PCOS
“(2)At baseline, patient had, or patient currently has, at least ONE of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease”
static.cigna.com · 2026-09-01- Lifestyle program
At least 3 months of diet and behavior change first, then continued alongside the drug (Cigna policy)
“ii. Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND … The medication will be used concomitantly with behavioral modification and a reduced-calorie diet”
static.cigna.com · 2026-09-01- 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
First approval lasts 8 months; 1-year renewals need 5%+ weight loss from baseline (Cigna policy)
“Initial Therapy. Approve for 8 months if the patient meets ALL of the following … Patient is Currently Receiving Zepbound. Approve for 1 year … iii. Patient has lost ≥ 5% of baseline body weight; AND”
static.cigna.com · 2026-09-01- Plan can exclude it?
Yes: only about half of Evernorth's employer clients cover Wegovy and Zepbound for weight loss
“The savings are available to Evernorth clients through a new benefit option … Currently, only half of its employer clients cover drugs like Wegovy and Zepbound for weight management, executives said on a call with investors earlier this month.”
healthcaredive.com · 2025-05-22- 2026 change
KwikPens and vials stay excluded on the 2027 formulary exclusion list, with Zepbound pens still a preferred alternative
“Weight Loss ZEPBOUND KWIKPENS, ZEPBOUND VIALS liraglutide, FOUNDAYO, WEGOVY HD, WEGOVY … PENS, WEGOVY TABLETS, ZEPBOUND PENS”
express-scripts.com · 2027 plan year
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: Yes: only about half of Evernorth's employer clients cover Wegovy and Zepbound 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 (Cigna policy). Conditions: Hypertension, type 2 diabetes, high cholesterol, sleep apnea, heart disease, knee arthritis, asthma, COPD, fatty liver disease, PCOS. Lifestyle program: At least 3 months of diet and behavior change first, then continued alongside the drug (Cigna policy).
- 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
What the documents say: First approval lasts 8 months; 1-year renewals need 5%+ weight loss from baseline (Cigna policy).
Get your real answer
Check your plan at express-scripts.com or the number on your ID card, and ask your prescriber to write for Zepbound pens, not KwikPens or vials, which the National Preferred Formulary excludes. The prescriber files prior authorization through esrx.com/PA.
Coverage is plan-specific: this page reports what Express Scripts publishes, not a promise about your plan. Not medical or insurance advice.
