The facts
Weight loss
Plan-dependent
Type 2 diabetes
Not verified
Prior auth
Plan sets it; criteria must be public
Typical cost
Plan-specific
The criteria, as published
5 of 9 criteria are stated in the FEHB (federal employees) 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
Each plan must cover at least one GLP-1 drug for weight loss; OPM does not name which
“OPM continues to require Carriers to provide a range of FDA-approved anti- obesity medications on their formulary, including at least one anti-obesity medication (AOM) from the GLP-1 class for weight loss and at least two (2) additional oral AOM options.”
opm.gov · 2026-03-31- 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
From plan year 2027, intensive behavioral therapy before and during treatment
“Prior authorization and utilization management for any AOM must ensure the member has demonstrated and will continue participation in lifestyle interventions meeting the rigor of IBT as referenced in this Technical Guidance before initiating treatment and while on an anti-obesity medication.”
opm.gov · 2026-03-31- 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
From plan year 2027, continued documented behavioral therapy while on the drug
“Continued participation and documentation of IBT should an AOM be prescribed.”
opm.gov · 2026-03-31- Plan can exclude it?
No: carriers may not exclude anti-obesity drugs through a benefit exclusion or carve out
“Carriers are not allowed to exclude anti-obesity medications from coverage based on a benefit exclusion or a carve out. … coverage of FDA approved anti-obesity medications on their formulary to meet member needs and must make available their exception process to members.”
opm.gov · 2025-04-25- 2026 change
OPM dropped its requirement that 2026 plans update their obesity benefit; stricter behavioral therapy rules apply from 2027
“Finally, in accordance with changing priorities, we no longer require Plan Year 2026 proposals to clarify or update the obesity management benefit to include the elements listed in the bullets starting on the bottom of page 10 and continuing through the bottom of page 12 of Carrier Letter 2025-01.”
opm.gov · 2025-01-31
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 FEHB (federal employees) 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: No: carriers may not exclude anti-obesity drugs through a benefit exclusion or carve out.
- 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. Lifestyle program: From plan year 2027, intensive behavioral therapy before and during treatment.
- 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: From plan year 2027, continued documented behavioral therapy while on the drug.
Get your real answer
Open your plan's 2026 brochure and drug formulary (linked from OPM's FEHB plan comparison tool) and search for Zepbound. Then call the pharmacy number on your member card and ask whether it is covered for weight loss, what the prior authorization criteria are, and whether you must join the plan's weight management or behavioral therapy program.
Coverage is plan-specific: this page reports what FEHB (federal employees) publishes, not a promise about your plan. Not medical or insurance advice.
