How to get a GLP-1 covered by insurance, in the order it actually works

There are four gates and most people fight the wrong one first. Before any clinical criterion applies, your employer has to have bought the weight-loss drug category at all, and if they did not, no BMI number and no comorbidity will change the answer. Once past that, the published criteria across the major insurers are strikingly consistent: BMI of 30 or more, or 27 with a weight-related condition, plus a documented period of lifestyle change, plus roughly 5 percent weight loss to stay approved at renewal.

Julian CaraulaniFounder, PriceTracker GLP-1Last checked Aug 28We track prices. Clinical facts on this site are quoted from the drug's label, the FDA or the published trial, with the source and the date beside each one. We do not write medical guidance and we do not tell anyone what to take.

8 min read · published Aug 28

The short version

  • 1Gate one is commercial, not clinical: did your employer buy the weight-loss benefit? If not, criteria are irrelevant.
  • 2Gate two is the formulary, run by a benefit manager rather than your insurer.
  • 3Gate three is the clinical criteria, and they are consistent: BMI 30, or 27 with a comorbidity, plus documented lifestyle change.
  • 4Gate four is renewal, which usually needs about 5 percent weight loss to keep the approval.

Most people fight the wrong gate first.

They arrive at the pharmacy counter with a BMI number, a blood pressure reading and a list of everything they have tried, and get told no for a reason none of that can touch. Here are the four gates in the order they actually apply, so you spend your effort on the one that is actually stopping you.

Gate one: did your employer buy the benefit at all?

This one is commercial, not medical, and it decides more cases than every clinical criterion combined.

Weight-loss drugs are usually an optional category that an employer either purchases or declines. UnitedHealthcare says so in the title of its own programme:1

This is an optional program that is put in place for clients or businesses that have elected to cover weight loss products with Prior Authorization/Notification.

UnitedHealthcare

Cigna puts it just as plainly:2

Weight loss medications are specifically excluded under many benefit plans.

Cigna
Worth knowing

If your plan does not include the category, there is no BMI number, no comorbidity and no letter that changes the answer, because there is nothing to appeal against. The drug is not being denied on your facts. It is not in your benefit.

The question to ask, in these words: does my plan include the weight-loss medication benefit? Ask HR or benefits rather than the pharmacy, because this is a plan-design question and the pharmacy cannot see the answer. Get it settled before you spend a single appointment on the clinical case.

Gate two: is the drug preferred on the formulary?

If the category is bought, the next gate is which brand within it. That list is set by a pharmacy benefit manager rather than by the insurer whose name is on your card, which is why formularies move independently of your plan.

This is where step therapy lives, and it can be steep. The Federal Employee Program's Zepbound policy requires you to have failed two oral weight-management drugs and to have tried the preferred products first:5

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

BCBS Federal Employee Program

Being told to try something else first is not the same as being told no. It is a sequence, and the sequence is documentable.

Gate three: the clinical criteria

Here is the reassuring part. Across the insurers we track, the published thresholds are remarkably consistent, so you can prepare for them without knowing whose logo is on your card.

The BMI test is essentially universal:2

At baseline, patient had a BMI ≥ 30 kg/m2; OR … BMI ≥ 27 kg/m2 … at least ONE of the following weight-related comorbidities

Cigna
30, or 27

The BMI thresholds nearly every published policy uses. The lower one needs a weight-related condition alongside it, commonly high blood pressure, type 2 diabetes, sleep apnea or dyslipidemia.

The lifestyle requirement is the one that catches people out, because it is retrospective. Aetna asks for six months of it before drug therapy starts:3

The patient has participated in a comprehensive weight management program … with continuing follow-up for at least 6 months prior to using drug therapy

Aetna

Cigna asks for three months of behavioural and dietary modification. Either way the point is the same: it has to be documented, in your chart, with dates. A year of genuine effort that nobody wrote down does not exist for this purpose. If you are early in this process, the single most useful thing you can do today is ask your prescriber to record what you are already doing, starting now.

Gate four: staying approved

The approval is not permanent, and the renewal has its own test. UnitedHealthcare issues an initial Wegovy authorisation for five months and then asks for results:4

Wegovy injection or tablet: Authorization will be issued for 5 months. … For Wegovy injection or tablet, weight loss of ≥ 5% of baseline body weight

UnitedHealthcare

So your baseline weight matters, and it needs to be in the record before you start rather than reconstructed afterwards. Around 5 percent is the common bar. That is a genuinely achievable number on these drugs, but only if someone is weighing you consistently and writing it down.

What to actually do, in order

  • Ask HR whether the weight-loss category is in your plan. One question, and it decides whether the rest of this matters.
  • Look up your own drug in your own plan's tool, not a general formulary. Every insurer has one and it is the only version that reflects your employer's choices.
  • Get your baseline recorded: weight, BMI, and any weight-related condition, with dates.
  • Get the lifestyle work documented from today, whether or not you have been doing it for a year already.
  • Ask your prescriber for the specific criteria document your plan uses. It exists, it is written down, and it tells you exactly what the reviewer will look for.
  • If the answer is still no, find out which gate it failed at, because only one of them is worth appealing.

We publish the verified answer for seven insurers across four brands, each quoted from the insurer's own material, at our coverage tracker. If yours came back as a denial, the denial page covers what is worth appealing and what is not.

And if none of it works

Cash-pay is cheaper than most people expect, and it is the number we re-verify weekly:

Worth reading first: what the manufacturer cards are really worth, since the advertised $25 is a best case rather than a price, and every cash route priced against the others.

Sources5
  1. UnitedHealthcare, weight-loss prior authorisation programme read Aug 20“This is an optional program that is put in place for clients or businesses that have elected to cover weight loss products with Prior Authorization/Notification.” ↩
  2. Cigna, weight-loss GLP-1 coverage policy read Aug 20“Weight loss medications are specifically excluded under many benefit plans … At baseline, patient had a BMI ≥ 30 kg/m2; OR … BMI ≥ 27 kg/m2 … at least ONE of the following weight-related comorbidities” ↩
  3. Aetna, weight-loss GLP-1 prior authorisation policy read Aug 20“The patient has participated in a comprehensive weight management program … with continuing follow-up for at least 6 months prior to using drug therapy” ↩
  4. UnitedHealthcare, reauthorisation requirement read Aug 20“Wegovy injection or tablet: Authorization will be issued for 5 months. … For Wegovy injection or tablet, weight loss of ≥ 5% of baseline body weight” ↩
  5. Blue Cross Blue Shield Federal Employee Program, Zepbound policy read Aug 20“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” ↩

Common questions

How do I get Wegovy covered by insurance?

First find out whether your employer bought the weight-loss drug benefit at all, because that decides most cases before any clinical criterion applies. If it is included, the published criteria are consistent across insurers: BMI of 30 or more, or 27 with a weight-related condition, plus a documented period of lifestyle and dietary change, usually three to six months. Your prescriber then submits the prior authorisation with that documentation.

Why was I denied even though I meet the BMI requirement?

Almost always because the denial was not about your BMI. If your plan excludes weight-loss medications as a category, the drug is not being refused on your facts and no clinical evidence changes it. The other common reasons are step therapy, meaning you have to try a preferred drug first, and missing documentation of the lifestyle requirement rather than missing effort.

What BMI do you need for insurance to cover a GLP-1?

The near-universal published threshold is a BMI of 30 or more, or 27 or more with at least one weight-related comorbidity such as high blood pressure, type 2 diabetes, sleep apnea or dyslipidemia. Some plan variants set a higher bar, so check the criteria document your own plan uses.

How long does a GLP-1 prior authorization last?

Typically five to twelve months for a first approval, then it has to be renewed. Renewal usually turns on results: UnitedHealthcare, for example, issues an initial Wegovy authorisation for five months and requires weight loss of at least 5 percent of baseline body weight to continue. That makes a recorded starting weight important before you begin.

Do I need to try other medications first?

Sometimes, and this is step therapy rather than a refusal. The BCBS Federal Employee Program's Zepbound policy, for instance, requires an inadequate response, intolerance or contraindication to at least two oral weight-management medications and that you have tried the preferred products first, unless there is a valid medical exception.

What if my employer does not cover weight-loss drugs?

Then coverage is not the route. Manufacturer savings cards need an insured copay to work on, so they do not help either. That leaves the manufacturers' own cash prices and the compounded telehealth market, which is cheaper again but not FDA-approved. We track and rank the cash options weekly.

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