GLP-1 Prior Authorization: What Insurers Actually Require

Prior authorization is the step where a health plan decides, before it pays, whether a prescription meets its written rules. For GLP-1 medicines used for weight management, it applies almost everywhere. GoodRx Research reports that 88 percent of people with commercial coverage for a weight-loss GLP-1 face restrictions such as prior authorization or step therapy [14]. That tracker blocked automated retrieval when we checked it on September 14, 2026, so treat the figure as a directional secondary-source number rather than a verified one.

The good news is that the rules are usually published. Several large payers post their criteria as public PDFs, and reading the one that applies to you turns a guessing game into a checklist. This article walks through what those documents say, using the real text. It is not medical advice, and it does not tell you what to take or at what dose — only a licensed healthcare provider can do that. Where it describes how a medicine is used, it is summarizing FDA-approved labeling and Instructions for Use; follow your own prescription and your prescriber’s directions.

What is prior authorization, and who decides?

Prior authorization is a contract term, not a clinical one. Your plan or its pharmacy benefit manager writes a policy listing the conditions under which it will pay. Your prescriber submits documentation. A reviewer compares the two. If the documentation matches the policy, the claim is approved; if not, it is denied and you can appeal.

Three separate restrictions often stack on the same drug:

• Prior authorization (PA) — approval needed before the plan pays.
• Step therapy (ST) — you must try one or more other drugs first.
• Quantity limit (QL) — a cap on how much is covered in a period.

You can clear one and still be blocked by another. Clearing all three still says nothing about your copay, which is set by the drug’s tier.

What BMI do insurers require?

The most common threshold mirrors the FDA label. UnitedHealthcare’s 2026 weight-loss program requires one of the following: a BMI of 30 or greater (or, for pediatric patients, a BMI above the 95th percentile); or a BMI of 27 or greater together with a weight-related comorbidity such as dyslipidemia, hypertension, type 2 diabetes or sleep apnea [1]. CVS Caremark’s published Wegovy criteria (policy 4774-C, revised August 25, 2026) use the same 30-or-27-with-comorbidity structure and add a pediatric pathway at the 95th percentile or greater standardized for age and sex, with documentation required at every step [3]. Aetna’s Zepbound policy requires the drug be used with a reduced-calorie diet and increased physical activity and applies the same BMI structure, with documentation explicitly required [4].

But the label threshold is not universal, and this is where people get surprised:

• 32, or 27 with two conditions. Evernorth’s EncircleRx program, sold to employers by Cigna and Express Scripts, tells providers that patients must have a BMI of 32 or higher, or a BMI of 27 or higher along with two weight-related health issues [6].
• 35. The Kansas State Employee Health Plan requires a BMI of 35 or higher for all weight-management GLP-1 prescriptions issued or renewed after January 1, 2026 [9].
• 40. UnitedHealthcare applies a separate, stricter section to North Dakota fully insured essential health benefit plans, requiring a BMI of 40 or greater, or a pediatric BMI above 120 percent of the 95th percentile [1]. Most ACA Marketplace carriers that cover these drugs use a BMI 40 floor as well.

One important exception in UnitedHealthcare’s policy: there is no BMI requirement when Wegovy injection is requested for MASH with moderate-to-advanced fibrosis. The policy’s own change log records that clarification in April 2026 [1].

What comorbidities count?

Policies list examples rather than closed sets, which gives clinicians some room but also means documentation matters. UnitedHealthcare names dyslipidemia, hypertension, type 2 diabetes and sleep apnea as examples [1]. Aetna names hypertension, type 2 diabetes mellitus and dyslipidemia [4]. The BCBS Federal Employee Program is more structured: for a BMI of 27 or greater it accepts either established cardiovascular disease — listing 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 — or at least one weight-related comorbid condition such as type 2 diabetes, dyslipidemia or hypertension [5].

The practical point is that the condition has to be documented in the chart, not merely mentioned. Payer guidance and provider-facing prior authorization guides both stress writing the diagnosis explicitly in the assessment, for example “obesity (BMI 37.2)” rather than a bare code.

Do I have to be in a lifestyle or weight-management program?

Frequently, yes, and the definition varies enormously.

At the permissive end, UnitedHealthcare requires only that the drug be “used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)” [1]. That is a statement a prescriber can make from the visit itself.

At the strict end, the BCBS Federal Employee Program requires documented participation in a comprehensive weight-management program, naming Teladoc or another weight-loss program as examples, both for initial approval and for renewal [5]. CVS Caremark goes further still: its Wegovy criteria require that the patient “has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy” [3]. Aetna’s Zepbound policy carries the same six-month prior-program requirement [4]. If your plan runs on Caremark or Aetna criteria, that six-month history is a common reason a first submission fails.

Some employers go further and name a vendor: Massachusetts Group Insurance Commission members had to be prescribed by a Vida Health provider from January 2026 until the arrangement ended that July, and Evernorth’s EncircleRx requires participation in an Evernorth-sponsored lifestyle modification program provided at no cost to the patient [6].

KFF’s 2025 Employer Health Benefits Survey found that 34 percent of firms covering these drugs for weight loss require enrollees to meet with a dietitian, case manager or therapist, or participate in a lifestyle program, before the drug is covered [15]. This is why two people with identical clinical pictures and the same insurance company can get different answers — one employer bought the program requirement, the other did not.

What is step therapy, and can I get around it?

Step therapy requires you to try a cheaper or preferred option first. For GLP-1s it shows up in two forms.

The first is preferred-versus-non-preferred within the class. The Kansas State Employee Health Plan makes Wegovy its preferred weight-management GLP-1 and treats Zepbound as non-preferred unless the member has already tried and failed a preferred product or cannot use it for medical reasons [9]. The BCBS FEP Zepbound policy likewise requires that the patient “MUST have tried the preferred product(s)… unless the patient has a valid medical exception” [5].

The second form is older, cheaper drugs first. The BCBS FEP policy requires inadequate treatment response, intolerance or contraindication to at least two oral medications for weight management — it gives benzphetamine, diethylpropion, phentermine and Qsymia as examples — before Zepbound will be approved [5]. That requirement catches a lot of federal employees off guard and is a common reason for a first-pass denial.

If a step requirement does not fit your situation, there is an exception process. Most states require insurers to grant a step therapy override when the required drug is contraindicated, is expected to be ineffective given known characteristics of the patient and drug, has already been tried and failed, would likely cause an adverse reaction, or when the patient is stable on the current medication [10]. Those state laws apply to fully insured plans. They generally do not reach self-funded employer plans, which are governed by federal ERISA rules — and most large employers self-fund [11]. In Medicare Part D, the equivalent request is a formulary exception, and once the plan has the prescriber’s supporting statement it must decide within 24 hours for an expedited request or 72 hours for a standard one [12].

How long does an approval last, and what does renewal require?

Initial approvals are deliberately short so the plan can check whether the drug is working.

UnitedHealthcare’s 2026 schedule is explicit: benzphetamine, diethylpropion, phendimetrazine and phentermine get 3 months; Contrave, Qsymia and Saxenda get 4 months; Wegovy injection, Wegovy tablet and Wegovy HD get 5 months; and Foundayo, Xenical and Zepbound get 6 months [1]. The BCBS Federal Employee Program gives Zepbound 6 months initially [5]. Aetna issues 8 months for initial Zepbound therapy [4].

Renewal turns on documented weight loss. UnitedHealthcare requires at least 5 percent of baseline body weight for Wegovy and Zepbound, at least 4 percent for Saxenda, at least 3 percent for Qsymia, and at least 5 percent for other appetite suppressants, plus continuation of lifestyle modification — then issues 12 months [1]. Aetna’s Zepbound policy requires at least 3 months of therapy at a stable maintenance dose and loss of at least 5 percent of baseline body weight, or maintenance of that loss, and then renews for 12 months [4]. BCBS FEP renews for 12 months on the same 5 percent test [5]. UnitedHealthcare’s renewal runs 12 months for Contrave, Foundayo, Qsymia, Saxenda, Wegovy, Wegovy HD, Xenical and Zepbound, and 6 months for the older appetite suppressants [1].

This creates a predictable trap. If your plan gates initial approval on a high BMI and you succeed, you may drop below that threshold before renewal. Several policies address it directly — Evernorth tells providers that for a patient already taking a GLP-1, the baseline BMI at the initial coverage review is the BMI used for coverage [6]; Aetna’s policy says to consider the baseline BMI and the weight-related comorbidity present at the start of any drug therapy when a patient transitions from another weight-loss drug [4]; and CVS Caremark’s Wegovy criteria carry the same instruction at every BMI criterion [3]. The fix is documentation: ask your prescriber’s office to keep the original baseline weight, BMI and date in the chart, and to state both baseline and current values in every renewal request.

What are the quantity limits?

UnitedHealthcare’s supply-limit list, updated August 21, 2026 for a September 1, 2026 effective date, gives exact caps [2]:

Product	Monthly quantity limit
Wegovy 0.25, 1, 1.7 mg/0.5 mL pens	4 pens
Wegovy 1.7, 2.4 mg/0.75 mL pens	4 pens
Wegovy 1.5, 4, 9 mg tablets	30 tablets (60 per 365 days)
Wegovy 25 mg tablets	30 tablets
Zepbound 2.5 mg autoinjectors or vials	4
Zepbound 5, 7.5, 10, 12.5, 15 mg autoinjectors or vials	4
Zepbound KwikPen (all strengths)	1 pen
Ozempic pens	1 pen
Mounjaro	4 pens
Saxenda	5 pens

Nearly every line carries the same note: two one-month fills are required before a three-month fill is available, if the plan allows three-month fills at all [2].

Other payers set limits differently. Cigna’s drug quantity management policy for Zepbound uses 2 mL (4 pens) per 28 days at retail and 6 mL (12 pens) per 84 days through home delivery, and states that override criteria were removed for the updated limits [8]. The BCBS Federal Employee Program allows 12 single-dose Zepbound pens per 84 days [5]. Medi-Cal restricts Wegovy and Saxenda to one carton per dispensing and one dispensing every 28 days [16].

If a refill rejects as too soon before travel, ask the pharmacist whether the plan permits a vacation or travel override, which is submitted with a claim clarification code; reporting suggests most plans allow roughly one such override every 180 days for chronic medications, though some policies allow none [13].

A quantity limit is a payment rule, not a dosing instruction, and the two can diverge. The FDA-approved labeling and Instructions for Use for each of these products set the dose and schedule — for example, Wegovy and Zepbound are labeled for once-weekly subcutaneous injection, and the Wegovy HD 7.2 mg dose is labeled for use only after a patient has tolerated 2.4 mg for at least four weeks. Only your prescriber can decide what you take and when; if a supply problem means you may run short, that is a conversation for your prescriber and pharmacist, not something to solve by changing how you use the medicine.

Why is one device covered and another is not?

Because formulary decisions are made at the product level, not the molecule level. On the Express Scripts 2026 National Preferred Formulary, the Weight Loss class excludes Zepbound KwikPens and Zepbound vials, while listing liraglutide, Foundayo, Wegovy HD, Wegovy pens, Wegovy tablets and Zepbound pens as preferred alternatives [7]. The Medicare GLP-1 Bridge does the opposite: it covers the Zepbound KwikPen and explicitly excludes the single-dose Zepbound pen and vials.

The lesson is to check the exact product and device on your formulary, and to have your prescriber write for the form your plan covers.

How do I read a prior authorization policy?

Payer criteria documents follow a standard shape. Look for these sections:

1. Program number and effective date. UnitedHealthcare’s is “2026 P 1114-22,” effective September 1, 2026 [1]. BCBS FEP’s Zepbound policy is “5.99.031,” effective July 1, 2026 [5]. If someone quotes criteria at you without a number and date, it may be out of date.
2. Initial authorization criteria, usually a list joined by AND with sub-lists joined by OR. Every AND must be satisfied.
3. Authorization duration.
4. Reauthorization criteria, usually the weight-loss percentage plus continued lifestyle modification.
5. Additional clinical rules, such as supply limits or “exclude at launch” status for new products. UnitedHealthcare flags that Foundayo and the Wegovy tablet may be excluded at launch on some plans [1].
6. Change control history. This is the most underused section. UnitedHealthcare’s log shows Zepbound added December 2023, cardiovascular risk reduction for Wegovy added May 2024, obstructive sleep apnea for Zepbound added March 2025, Wegovy’s initial authorization shortened to 5 months in May 2025, MASH added November 2025, the Wegovy tablet added February 2026, the MASH BMI clarification in April 2026, and Foundayo and Wegovy HD added May 2026 [1]. It tells you how fast the rules move.

What this means in practice

Get the criteria document with its number and date. Go through it line by line with your prescriber’s office before the first submission, not after a denial. Make sure baseline weight and BMI are recorded with dates. Confirm the device form matches the formulary. Ask about the quantity limit and the 90-day rule. And put a reminder in your calendar a month before the authorization expires, because a lapsed authorization is a full restart.

Sources

1. UnitedHealthcare, Prior Authorization/Notification — Plans with Weight Loss/Appetite Suppression Medication Coverage (Program 2026 P 1114-22), effective September 1, 2026. https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/r-z/PA-Notification-Weight-Loss.pdf
2. UnitedHealthcare, Quantity Limits per duration — Pharmacy Benefit, updated August 21, 2026. https://www.uhcprovider.com/content/dam/provider/docs/public/resources/pharmacy/Quality-Duration-Supply-Limits.pdf
3. CVS Caremark, Initial Prior Authorization with Quantity Limit — Wegovy (4774-C), revised August 25, 2026. https://info.caremark.com/content/dam/enterprise/caremark/microsites/dig/pdfs/pa-cf/cf_rxcriteria/CF_RxCriteria_WEGOVY_4774-C.pdf
4. Aetna, Zepbound PA with Limit 6192-C — Pharmacy Clinical Policy Bulletin. https://www.aetna.com/products/rxnonmedicare/data/2024/Zepbound_PA_with_Limit_6192-C_P08-2024_R.html
5. Blue Cross Blue Shield Association / FEP, Policy 5.99.031 — Zepbound, effective July 1, 2026. https://info.caremark.com/content/dam/enterprise/caremark/microsites/dig/pdfs/pa-fep/fep-criteria/FEP_Criteria_Zepbound.pdf
6. Evernorth, EncircleRx Provider GLP-1 Program. https://www.evernorth.com/encirclerx-provider
7. Express Scripts, 2026 National Preferred Formulary Exclusions. https://www.express-scripts.com/art/open_enrollment/DrugListExclusionsAndAlternatives.pdf
8. Cigna, Zepbound Drug Quantity Management Policy — Per Days. https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_840_coveragepositioncriteria_zepbound_dqm_per_days.pdf
9. Kansas State Employee Health Plan, GLP-1s. https://sehp.healthbenefitsprogram.ks.gov/glp-1s
10. Triage Cancer, Health Insurance State Laws: Step Therapy. https://triagecancer.org/state-laws/health-insurance-step-therapy
11. Step Therapy Coalition, Step Therapy Legislation By State. https://steptherapy.com/step-therapy-legislation-by-state
12. Centers for Medicare & Medicaid Services, Exceptions. https://www.cms.gov/medicare/appeals-grievances/prescription-drug/exceptions
13. Rx.com, Vacation Override for Ozempic, Wegovy & Zepbound. https://rx.com/education/vacation-override-ozempic-wegovy-zepbound
14. GoodRx Research, Tracking insurance coverage for weight-loss medications, 2026. Figures captured from indexed excerpts; the live page returned HTTP 403 to automated retrieval on September 14, 2026. https://www.goodrx.com/healthcare-access/research/tracking-insurance-coverage-weight-loss-meds
15. KFF, 2025 Employer Health Benefits Survey, published October 22, 2025. https://www.kff.org/health-costs/2025-employer-health-benefits-survey
16. Medi-Cal Rx, California DHCS, Reminder: Quantity Limit Restrictions for Anti-Obesity Preparations, July 2024. https://medi-calrx.dhcs.ca.gov/cms/medicalrx/static-assets/documents/provider/pharmacy-news/2024.07_A_Reminder_Quantity_Limit_Restrictions_Anti-Obesity_Preparations.pdf