GLP-1 Prior Authorization Requirements: What Insurers Ask For

Before a plan will cover a GLP-1 for weight loss, it usually requires four things: a documented BMI of 30 or higher (or 27 or higher with a weight-related condition such as hypertension or type 2 diabetes), proof of participation in a weight management program, documentation of every qualifying condition, and — at renewal — evidence of at least 5% weight loss from baseline ^[1][3][4][5]. Some payers add more: BCBS Federal Employee Program requires inadequate treatment response, intolerance, or contraindication to at least two oral weight-management medications ^[5], and Evernorth’s EncircleRx program requires enrollment in its own lifestyle program before a prior authorization can even be submitted ^[6].

Every one of these rules is plan-specific and date-stamped. UnitedHealthcare’s weight-loss prior authorization program (2026 P 1114-22, effective September 1, 2026) is optional and only applies to employer clients that elected to cover weight-loss drugs ^[1]. CVS Caremark’s Wegovy criteria (document 4774-C), Aetna’s Zepbound criteria (6192-C), and the BCBS FEP Zepbound policy (5.99.031, effective July 1, 2026) each apply to their own plans only ^[3][4][5]. None of them is a treatment guideline — Cigna’s policies state explicitly that coverage policies “are not recommendations for treatment and should never be used as treatment guidelines” ^[8].

What is prior authorization for a GLP-1, and who writes the rules?

Prior authorization (PA) is the insurer’s review step: the plan checks the request against its published criteria before it will cover the drug. BCBS FEP describes the purpose in its Zepbound policy: “Prior authorization is required to ensure the safe, clinically appropriate, and cost-effective use of Zepbound while maintaining optimal therapeutic outcomes” ^[5]. Each payer publishes its criteria as a numbered policy document with an effective date. UnitedHealthcare’s is program 2026 P 1114-22, effective September 1, 2026 ^[1]. BCBS FEP’s Zepbound policy is 5.99.031, effective July 1, 2026, with an original policy date of September 9, 2022 and a last review date of June 11, 2026 ^[5]. Aetna’s non-Medicare Zepbound policy is PA with Limit 6192-C ^[4], and CVS Caremark’s Wegovy criteria document is 4774-C ^[3].

UnitedHealthcare describes its weight-loss PA program as optional — it is put in place for clients or businesses that elected to cover weight-loss products, and it is also designed to meet regulatory requirements in California, New Mexico, North Dakota Essential Health Benefits, and New York ^[1]. The policy notes that state mandates, federal requirements, and the member’s specific benefit plan may alter the criteria ^[1].

Two warnings appear across these documents. BCBS FEP states that approved requests are subject to review by a clinical specialist for final validation, and that current utilization, including samples, does not guarantee approval ^[5]. Evernorth warns that without required documentation, the prescription may be denied and the full cost of the medication falls to the patient ^[6].

What BMI do you need for insurance to cover Wegovy or Zepbound?

The most common threshold is a BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related comorbidity. That is the baseline rule in the UnitedHealthcare, CVS Caremark (Wegovy), Aetna (Zepbound), and BCBS FEP (Zepbound) policies ^[1][3][4][5]. But the number moves depending on who manages the pharmacy benefit:

Payer / program	BMI threshold for weight-loss coverage
UnitedHealthcare (general criteria)	≥30, or pediatric BMI ≥95th percentile; or ≥27 with a weight-related comorbidity [1]
UnitedHealthcare (North Dakota fully insured EHB, small group and individual)	≥40, or pediatric BMI ≥120% of the 95th percentile [1]
CVS Caremark Wegovy (adult)	≥30, or ≥27 with at least one comorbidity; documentation required [3]
CVS Caremark Wegovy (pediatric, 12–17, injection only)	BMI ≥95th percentile standardized for age and sex [3]
Aetna Zepbound	≥30, or ≥27 with at least one comorbidity; documentation required [4]
BCBS FEP Zepbound	≥30, or ≥27 with established cardiovascular disease or at least one comorbidity [5]
Evernorth EncircleRx	BMI 32 or higher, or BMI 27 or higher with two weight-related health issues [6]

The North Dakota figure is the outlier: for fully insured small group and individual plans in that state, UnitedHealthcare requires a BMI of 40 or higher — the threshold for class III obesity in the policy’s own classification table (class I is 30.00–34.99, class II is 35.00–39.99, class III is 40.00 and above) ^[1].

There is one situation where BMI drops out of the equation entirely: UnitedHealthcare applies no BMI criterion when Wegovy injection is requested for MASH (metabolic dysfunction-associated steatohepatitis) ^[1].

Which weight-related comorbidities count?

The lists overlap but are not identical. UnitedHealthcare gives dyslipidemia, hypertension, type 2 diabetes, and sleep apnea as examples ^[1]. Aetna and CVS Caremark list hypertension, type 2 diabetes mellitus, and dyslipidemia ^[3][4]. BCBS FEP accepts type 2 diabetes mellitus, dyslipidemia, or hypertension — and separately accepts established cardiovascular disease, defined to include congenital heart disease, cerebrovascular disease, peripheral artery disease, coronary heart disease, acute coronary syndrome, myocardial infarction, unstable angina, coronary or other arterial revascularization, or prior percutaneous coronary intervention or bypass surgery ^[5].

Evernorth’s EncircleRx list is the longest: knee osteoarthritis, asthma, COPD, cardiovascular disease, high blood pressure, high cholesterol, non-alcoholic fatty liver disease, obstructive sleep apnea, polycystic ovarian syndrome, and type 2 diabetes ^[6].

Documentation is not optional. CVS Caremark and Aetna print “ACTION REQUIRED: Documentation is required for approval” at each BMI and comorbidity criterion ^[3][4], and BCBS FEP requires documentation such as medical records and laboratory reports ^[5]. Both CVS Caremark and Aetna add a note for patients switching from another weight-loss drug: the comorbidity is considered as of the start of any drug therapy ^[3][4].

How old do you have to be?

For adults the answer is simple: 18 or older under the CVS Caremark Wegovy adult pathway and the BCBS FEP Zepbound policy ^[3][5]. For adolescents it depends on the product and the payer. UnitedHealthcare requires age 12 or older for Qsymia, Saxenda, Wegovy injection, and Xenical, and older than 16 for all other listed products — which includes Zepbound ^[1]; in its North Dakota EHB section, it requires 12 or older for Wegovy injection and older than 16 for Wegovy HD and Zepbound ^[1]. CVS Caremark’s pediatric Wegovy pathway covers ages 12 to 17, injection only ^[3].

BCBS FEP is stricter on Zepbound: it requires 18 years or older at both initial approval and renewal, citing the label statement that safety and effectiveness in patients under 18 have not been established ^[5].

Do you really need 6 months in a weight management program first?

For several major payers, yes — it is a written requirement, not a suggestion. CVS Caremark’s Wegovy weight-loss pathway requires participation in a comprehensive weight management program that encourages behavioral modification, a reduced-calorie diet, and increased physical activity, with continuing follow-up, for at least 6 months prior to drug therapy ^[3]. Aetna’s Zepbound policy carries the identical 6-month requirement ^[4].

UnitedHealthcare’s wording is looser: the drug must be used as an adjunct to lifestyle modification, with examples including dietary or caloric restriction, exercise, behavioral support, or a community-based program ^[1]. BCBS FEP requires participation in a comprehensive weight management program — it names Teladoc or another weight loss program as examples — at both initial approval and renewal ^[5].

Evernorth’s EncircleRx program is the strictest about sequence. Patients must enroll in an Evernorth-sponsored lifestyle modification program at no extra cost, and the prior authorization cannot be completed before enrollment — the steps must be performed in order ^[6]. “Active engagement” is defined as four weigh-ins and four app engagements per month, and for the first 30 days enrollment alone satisfies the engagement requirement while the patient’s equipment ships ^[6]. Patients enroll through express-scripts.com/healthsolutions under the Health Solutions tab; prescribers submit the PA through the EviCore by Evernorth portal at evicore.com or by calling Express Scripts at 800.417.1764 — the provider line is 800.282.2881 ^[6]. The impacted drugs are Wegovy, Zepbound, Saxenda (plan design may apply), and Foundayo ^[6].

Across Caremark, Aetna, and FEP, the drug must also be used with a reduced-calorie diet and increased physical activity — the same pairing the FDA labels require ^[3][4][5].

Do you have to try phentermine or other older drugs first?

Under BCBS FEP, there is a step requirement. The Zepbound policy requires inadequate treatment response, intolerance, or contraindication to at least two oral weight-management medications — it names benzphetamine, diethylpropion, phentermine, and Qsymia as examples ^[5]. Note that a contraindication can qualify without the drug ever having been taken. FEP also requires that the patient has tried the preferred product(s) unless there is a valid medical exception such as inadequate response, intolerance, or contraindication, at both initial approval and renewal ^[5].

The other payers in these documents do not publish a similar oral-drug-first requirement for Wegovy or Zepbound weight-loss coverage — UnitedHealthcare, CVS Caremark, and Aetna structure their criteria around BMI, comorbidity, program participation, and documentation instead ^[1][3][4].

One rule all of them echo: no combining GLP-1s. BCBS FEP prohibits dual therapy with other GLP-1 receptor agonists and with another PA weight-loss drug, listing Trulicity, Byetta, Bydureon/BCise, Saxenda, Victoza, Xultophy, Adlyxin, Soliqua, Ozempic, Rybelsus, Wegovy, Mounjaro, and Zepbound in its GLP-1 appendix ^[5]. CVS Caremark, Aetna, and FEP all repeat the label limitation that coadministration of semaglutide or tirzepatide products with any other GLP-1 receptor agonist is not recommended ^[3][4][5].

If a drug is excluded from a formulary rather than gated by PA, there is a separate path: Express Scripts’ National Preferred Formulary excludes listed drugs and directs patients to ask their physician to switch to a preferred alternative or request a coverage review at esrx.com/PA ^[7].

How long does the first approval last?

Initial approval durations differ by payer and by drug:

Payer	Drug	Initial approval duration
UnitedHealthcare	Wegovy injection or tablet, Wegovy HD	5 months [1]
UnitedHealthcare	Zepbound, Foundayo, Xenical	6 months [1]
UnitedHealthcare	Contrave, Qsymia, Saxenda	4 months [1]
UnitedHealthcare	benzphetamine, diethylpropion, phendimetrazine, phentermine	3 months [1]
Aetna (6192-C)	Zepbound	8 months initial; 12 months continuation [4]
BCBS FEP (5.99.031)	Zepbound	6 months initial; 12 months renewal [5]

UnitedHealthcare’s renewal durations run 12 months for Contrave, Foundayo, Qsymia, Saxenda, Wegovy injection or tablet, Wegovy HD, Xenical, and Zepbound, and 6 months for the older appetite suppressants ^[1]. Evernorth’s EncircleRx currently sets no limit on how long an approved patient can stay on a GLP-1 ^[6].

What happens at renewal — the 5% weight-loss test

Nearly every policy uses the same yardstick: weight loss of at least 5% of baseline body weight, or maintenance of an initial 5% loss. UnitedHealthcare requires ≥5% for Wegovy injection or tablet and Wegovy HD (and for all other appetite suppressants), with lower bars of ≥3% for Qsymia and ≥4% for Saxenda — plus continuation of lifestyle modification ^[1]. Aetna requires at least 3 months of therapy at a stable maintenance dose plus a loss of ≥5% of baseline body weight, or maintenance of that 5% loss ^[4]. CVS Caremark’s adult Wegovy continuation matches that language ^[3]. BCBS FEP requires the 5% loss or maintenance plus continued program participation ^[5].

UnitedHealthcare has a separate renewal pathway for Wegovy injection used for MASH: documentation of a positive clinical response (such as improvement or stabilization of fibrosis) and no progression to cirrhosis ^[1].

BCBS FEP also cites labeling guidance that patients should be evaluated for BMI decrease after 12–16 weeks of treatment, with discontinuation if no appropriate decrease has occurred ^[5].

What happens if your BMI drops below the threshold after losing weight?

Policies handle this through the concept of a baseline. Evernorth states it directly: for patients already on a GLP-1, the BMI at the initial coverage review is the BMI used for coverage ^[6]. CVS Caremark and Aetna include a note at each BMI criterion that if the patient is transitioning from another weight-loss drug therapy, the baseline BMI is considered at the start of any drug therapy ^[3][4]. In other words, the qualifying BMI is the one documented before treatment began, not the current number after weight loss.

Evernorth adds that patients already on a GLP-1 must enroll in the lifestyle program and have their coverage review re-evaluated under the updated criteria ^[6].

What is a quantity limit on Wegovy or Zepbound?

A quantity limit caps how much of a drug the plan covers per fill period. It is a coverage rule, not a dosing instruction — how much to take is a question for a prescriber or pharmacist.

Aetna’s Zepbound policy sets the limit at 2 mL per 21 days — one package of 4 pens or 4 single-dose vials — for all strengths from 2.5 mg to 15 mg, and 6 mL per 63 days — 3 packages of 4 pens or 12 single-dose vials — for the 3-month fill ^[4]. Aetna explains that 21 days is used for a 28-day fill period and 63 days for an 84-day fill period to allow time for refill processing ^[4]. BCBS FEP caps Zepbound at 12 single-dose pens per 84 days, at both initial approval and renewal ^[5].

UnitedHealthcare maintains a separate quantity-limits-per-duration list, last updated August 21, 2026 for a September 1, 2026 effective date ^[2]. The list defines supply limits as the maximum quantity covered in a copay or specified timeframe, marks some lines with an overrides column (Yes/No), and cautions that inclusion on the list does not mean the drug is covered by a given plan — any drug may also be subject to Exclude at Launch or Review at Launch ^[2]. UnitedHealthcare’s PA policy itself states only that “supply limits may be in place” ^[1]. Cigna maintains its own Zepbound Drug Quantity Management policy on a per-days basis, with a review date of October 30, 2024 and revisions on January 7, 2025, January 8, 2025, March 12, 2025, and July 16, 2025 ^[8].

Why the exact product and indication change the answer

The specific device or indication matters as much as the drug name. UnitedHealthcare notes that Foundayo and the Wegovy tablet may be in Exclude at Launch status ^[1]. Several CVS Caremark Wegovy pathways exclude the Wegovy HD 7.2 mg injection and/or Wegovy tablets — the MASH, pediatric, and cardiovascular risk pathways all do ^[3].

Non-weight-loss indications have their own criteria. UnitedHealthcare covers Wegovy for MACE risk reduction with established cardiovascular disease (prior myocardial infarction, ischemic or hemorrhagic stroke, or peripheral arterial disease), Wegovy injection for MASH with fibrosis stage F2 or F3, and Zepbound for moderate-to-severe obstructive sleep apnea ^[1]. CVS Caremark’s MASH pathway adds that the drug must be prescribed by or in consultation with a gastroenterologist or hepatologist, with F2–F3 fibrosis confirmed by non-invasive assessment (elastography, MRE) or historical biopsy ^[3]. Its cardiovascular pathway requires a baseline BMI of 27 or higher, that the patient does not have type 2 diabetes (Ozempic is noted instead), and that the patient is on guideline-directed medical therapy or has a clinical reason not to be ^[3].

UnitedHealthcare also routes plans that do not cover weight-loss drugs to separate Nonformulary Wegovy and Nonformulary Zepbound criteria ^[1].

How do you read a payer criteria document?

These documents follow a predictable structure: criteria are written as “ALL of the following” (AND logic) with nested “ONE of the following” (OR) lists ^[1][3][4][5]. Standard sections include indications and regulatory status, coverage criteria, continuation of therapy, duration of approval, quantity limits, and policy history ^[4][5].

The policy history shows how often the rules move. BCBS FEP’s Zepbound policy added weight-loss drugs to PA in January 2023, added the comprehensive program requirement in December 2023, added Zepbound as a non-preferred option on MedEx in January 2024, added established CVD for overweight patients in April 2024, placed Zepbound on its own policy (5.99.030, from 5.99.027) in December 2024, added the OSA indication and the GLP-1 thyroid boxed warning in February 2025, added a documentation requirement in December 2025, and completed its annual review in June 2026 ^[5]. UnitedHealthcare’s P&T approval dates run from January 2008 through May 2026 for a September 1, 2026 effective date ^[1].

What safety items will you see quoted in the policy?

Policies quote the FDA label, so patients see label language inside coverage documents. Zepbound carries a boxed warning about thyroid C-cell tumors, including medullary thyroid carcinoma, seen in rats, and is contraindicated in patients with a personal or family history of MTC or MEN 2 ^[5]. Zepbound’s FDA indications are chronic weight management in adults with obesity (BMI ≥30) or overweight (BMI ≥27) with at least one weight-related comorbidity, and moderate-to-severe OSA in adults with obesity ^[5].

Wegovy injection’s FDA indications include MACE risk reduction, weight reduction in adults and pediatric patients 12 and older, and noncirrhotic MASH with F2–F3 fibrosis under accelerated approval ^[3]. Wegovy tablets are indicated for MACE risk reduction and weight reduction in adults only ^[3].

What should be in hand before the request goes in?

Based on what these policies demand, the submission package needs: the policy number and effective date for the plan’s criteria; a documented baseline weight and BMI; documentation of any qualifying comorbidity; evidence of weight-management program participation; the correct product and device form (injection versus tablet, and strength exclusions like Wegovy HD 7.2 mg); awareness of the plan’s quantity limit; and a tracked renewal date ^[1][3][4][5]. Evernorth’s warning applies everywhere: without the required documentation, the prescription may be denied and the full medication cost falls to the patient ^[6].

Coverage criteria are not treatment guidance — they are the insurer’s conditions for payment, and they differ from plan to plan and change on their own schedules ^[1][5][8].

Sources

1. UnitedHealthcare Pharmacy. Prior Authorization/Notification - Plans with Weight Loss/Appetite Suppression Medication Coverage. Program Number 2026P1114-22.
2. UnitedHealthcare Pharmacy Benefit. Quantity Duration (QD) Limits per Duration Medication List - UnitedHealthcare Commercial Plans. Last updated August 21, 2026.
3. CVS Caremark. Initial Prior Authorization with Quantity Limit - Wegovy Weight Loss Management.
4. Aetna. Pharmacy Clinical Policy Bulletins: Zepbound PA with Limit 6192-C P08-2024_R. Non-Medicare Prescription Drug Plan.
5. Blue Cross Blue Shield Association. Zepbound (formulary exclusion). Effective July 1, 2026. Last review date June 11, 2026.
6. Evernorth. Provider information on our GLP-1 program - EncircleRx.
7. Express Scripts. 2026 Express Scripts National Preferred Formulary Exclusions.
8. Cigna. Weight Loss - Zepbound Drug Quantity Management Policy - Per Days. Review date October 30, 2024; selected revisions through July 16, 2025.
9. Kansas State Employee Health Plan. GLP-1s - Weight Management Options and How it Works.
10. Triage Cancer. Health Insurance State Laws: Step Therapy.
11. National Psoriasis Foundation. Step Therapy Legislation By State.
12. Centers for Medicare & Medicaid Services. Exceptions.
13. Rx.com. Need an Early Refill? How to Get a Vacation Override for Ozempic, Wegovy, and Zepbound.
14. GoodRx. Live Updates: Insurance Coverage for GIP and GLP-1 Agonists Like Zepbound & Wegovy in 2026.
15. KFF. 2025 Employer Health Benefits Survey. October 22, 2025.
16. Medi-Cal Rx. Reminder: Quantity Limit Restrictions for Anti-Obesity Preparations. July 24, 2024.