Weight Loss Drugs (GLP-1) Coverage
GLP-1 medications, also known as glucagon-like peptide-1 receptor agonists (GLP-1Ras), mimic the hormone GLP-1 in the body. This hormone helps control blood glucose levels, insulin production, and feelings of fullness. GLP-1 medications treat type 2 diabetes and assist in weight management.
The guidelines for weight loss drugs are continually being updated.
Yes, for ACA-compliant plans only. This coverage is specifically excluded from AFA (Aetna Funding Advantage) plans.
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
GLP-1 Coverage Details and Criteria:
- Clinical criteria can be found on the Aetna public site for providers. Health care professionals also may obtain information by calling the Pharmacy Management Precertification Unit at 1-800-414-2386, or they can register to use the password-protected provider website. Visit www.aetna.com, select "Doctors & Hospitals" and choose "Physician Self-Service." Once registration is completed, health care professionals may use our online Precertification/medical exception email request form.
- Clinical Policy Bulletins on the public provider site here can be shared with members/providers for criteria. The bottom of the page has a “Pharmacy Criteria” search box.
Because coverage approval can vary depending on the member's plan, please direct members to the CPB link and their specific plan benefits to check if coverage is approved. The Clinical Policy Bulletins available on the public provider site can be shared with members and providers for reference on eligibility criteria. At the bottom of the page, there is a “Pharmacy Criteria” search box that can be utilized.
Is the coverage full, or is it at 50%?
Because coverage approval can vary depending on the member's plan, please direct members to the CPB link and their specific plan benefits to check if coverage is approved (and at what level). The Clinical Policy Bulletins available on the public provider site can be shared with members and providers for reference on eligibility criteria. At the bottom of the page, there is a “Pharmacy Criteria” search box that can be utilized.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Because coverage approval can vary depending on the member's plan, please direct members to the CPB link and their specific plan benefits to check if coverage is approved. The Clinical Policy Bulletins available on the public provider site can be shared with members and providers for reference on eligibility criteria. At the bottom of the page, there is a “Pharmacy Criteria” search box that can be utilized.
Supporting Collateral:
- Middle Market Formulary:
- The formularies indicate which brands are covered, the pharmacy tier, and if step therapy/prior authorization is required. Find a Medication: Prescription Drug List (Formulary), Coverage & Costs | Aetna
- Middle Market (Fully Insured) – Advanced Control Plan – California
- Middle Market and Small Group (AFA) - Advanced Control Plan
- The formularies indicate which brands are covered, the pharmacy tier, and if step therapy/prior authorization is required. Find a Medication: Prescription Drug List (Formulary), Coverage & Costs | Aetna
- Small Group Formulary:
- For AFA small group level-funded plans, coverage for weight loss medications is excluded.
- On the CA ACA plans, the information below applies.
- There are two separate formularies, one for HMO and one for PPO.
- 2026 Formulary Links:
- SG CA ACA HMO: 2026 Aetna Health Exchange Plan – CA SG HMO
- SG CA ACA OAMC/PPO: 2026 Aetna Health Exchange Plan - CA SG PPO
(California)Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Yes
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
Yes.
When prescribed solely to lose weight, except for the Medically Necessary treatment of morbid obesity. Members who are prescribed weight loss drugs that are Medically Necessary for the treatment of morbid obesity may be required to enroll in a comprehensive weight loss program, which is approved and covered by the Plan, for a reasonable period before or concurrent with receiving the Prescription Drug.
Are there coverage limits (e.g., 6 months, one year, etc.)?
Yes.
Members who are prescribed weight loss drugs that are Medically Necessary for the treatment of morbid obesity may be required to enroll in a comprehensive weight loss program, which is approved and covered by the Plan, for a reasonable period before or concurrent with receiving the Prescription Drug.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Yes.
Members who are prescribed weight loss drugs that are Medically Necessary for the treatment of morbid obesity may be required to enroll in a comprehensive weight loss program, which is approved and covered by the Plan.
Supporting Collateral:
- GLP-1 Receptor Agonist
- Mounjaro Information
- Zepbound Information
- Ozempic, Trulicity, and Victoza - tier 2 but needs prior authorization.
- Trulicity and Bydureon - non-formulary. Needs prior authorization.
- Mounjaro is non-formulary/specialty- it needs prior authorization.
- Wegovy is non-formulary; it will need prior authorization. This drug was recently approved for Cardiovascular risk reduction.
- Zepbound is non-formulary and will require PA. This is the drug that might be the hardest to approve since it is only approved for weight loss.
(Nevada)
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?Anthem Blue Cross Blue Shield does not provide coverage for this benefit in Nevada for large group fully insured plans.
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
There is no universal coverage policy for all GLP-1 medications. They are approved for diabetes treatment with prior authorization, which is typically granted after step therapy (ex. Metformin was shown as ineffective).
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
N/A
Supporting Collateral:
Click HERE to view the GLP-1 Receptor Agonists and GIP-GLP-1 Receptor Agonists clinical criteria.
Covered Medications:
GLP 1 medications are covered for diabetes. Review the clinical approval criteria for two of the most frequently requested medications –Ozempic and Mounjaro, both classified as Tier 2. Click below to view the details.
- Nevada Select Drug List: https://client.formularynavigator.com/Search.aspx?siteCode=6044536062
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Do any of your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary?
Yes, GLP-1s can be covered under certain criteria.
- Members must meet certain criteria to be eligible for weight loss drug coverage.
- Plan coverage and prior authorization are required for all weight-loss medications.
Yes, a member must have participated in a comprehensive weight management program for at least six months in the past year.
Coverage and prior authorization:
- The FDA has approved different GLP-1 drugs for specific uses.
- Drugs like Wegovy and Zepbound are specifically approved for use in chronic weight management only.
- Drugs like Ozempic and Mounjaro are only approved for use in the treatment of Type 2 diabetes.
- GLP1s that are FDA-approved for the treatment of obesity require prior authorization. Members must meet specific lifestyle modification requirements, BMI thresholds, and/or have certain co-morbid conditions that may qualify for GLP-1s. New members starting a GLP-1 for weight loss must have a BMI of 40 or higher to qualify for coverage.
- The most up-to-date formulary information can be found on our Drug Formularies page here.
- Click here to view the article on Producer Connection
- Blue Shield of California members may have access to Wellvolution® programs that meet the weight management criteria. Wellvolution is a digital platform with lifestyle-based tools and support designed to help members lose weight, treat diabetes, nurture mental health, and more. Wellvolution platform.
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Yes. All weight loss drugs require prior approval based on Health Net’s drug use guidelines
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
For approval, Health Net Medical Necessity criteria must be met based on:
- BMI (Body Mass Index)
- Documentation of member’s baseline and current height and body weight within the last 30 days
- Other medical issues
- Documentation supporting member’s participation in a Health Net-approved weight loss program (e.g., Weight Watchers) or other weight loss programs recommended by the prescriber that involves:
- a reduced calorie diet
- increased physical activity and
- behavioral modification.
No, however, Health Net will requalify.
Is the coverage full or is it at 50%?
Benefits will depend on the plan enrolled on.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Yes, documentation supporting member’s participation in a Health Net-approved weight loss program (e.g., Weight Watchers) or other weight loss programs recommended by the prescriber that involves:
- a reduced calorie diet
- increased physical activity and behavioral modification.
- To request prior authorization, the prescriber must complete and fax a Prior Authorization form (PDF) to 866-399-0929.
- To access Pharmacy Prior Authorization Guidelines, please refer to: Health Net Commercial Drug Coverage Policies | Health Net
- To access the List of Covered Drugs based on group size, please refer to: Employer Group Drug List | Health Net
| Drug Name | FDA Approved Indications | Notes |
| Ozempic Self-injection: Dosing once a week |
OZEMPIC® is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as:
|
Weight Loss – Not Covered Coverage requires prior authorization. Based on BMI and other medical conditions. |
| Saxenda (self-injected medication): Dosing is daily |
SAXENDA® is a glucagon−like peptide−1 (GLP−1) receptor agonist indicated:
Adult patients with an initial body mass index (BMI) of:
|
Weight Loss – Covered Coverage requires prior authorization. Based on BMI and other medical conditions. |
| Wegovy (self-injected medication): Dosing is weekly |
WEGOVY® is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated in combination with a reduced calorie diet and increased physical activity:
Adult patients with an initial body mass index (BMI) of:
|
Weight loss is covered. Coverage Requires prior authorization. Based on BMI and other medical conditions |
| Zepbound (self-injected medication): Dosing is weekly |
ZEPBOUND® is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist indicated in combination with a reduced-calorie diet and increased physical activity:
Adult patients with an initial body mass index (BMI) of:
|
Weight loss is covered. Coverage requires prior authorization. Based on BMI and other medical conditions. |
| Mounjaro: Dosing is weekly |
MOUNJARO® is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. | Weight loss is not covered |
Current as of 3/25/26
Do any of your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary?
Yes.
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
Yes, listed at https://healthy.kaiserpermanente.org/health-wellness/weight-management/weight-loss-coverage.
Are there coverage limits (e.g., 6 months, one year, etc.)?
Kaiser Permanente members who started a weight management drug program overseen by their doctor when they had a BMI of 40 or above will still have access to these drugs for up to 24 months. And Kaiser Permanente members whose BMI is still 40 or above after 24 months of treatment will continue to have access to these drugs.
Is the coverage full, or is it at 50%?
Not covered at 100%. Cost depends on the plan.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently with receiving the weight loss drug?
Doctors will review the member’s medical history, learn more about their goals, and discuss where they are in your weight management journey. The doctor will work closely with the member to find the best evidence-based care options — and help manage them over time. The members’ personalized treatment plan may include:
- Diet and exercise
- Mental health and wellness
- Self-care resources
- Social health support, such as housing and relationship counseling
- Classes and coaching
- Medication or medical treatment, such as bariatric surgery
- Yes, to explore resources for maintaining a healthy weight, visit kp.org/weightmanagement.
- For more information, please contact kp.org/supportcenter.
See the Kaiser Permanente Formulary (covered drugs) posted on KP.org – Ozempic.
Current as of 3/17/26
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
No.
MediExcel providers adhere to medical practice standards in Mexico that do not approve the use of GLP-1 medications for weight loss. Furthermore, MediExcel Health Plan does not cover these medications for weight loss or glucose management.
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
Excel Hospital/MediExcel Medical Group, Mexicali offers a weight loss program consisting of internal medicine, nutrition, and psychology office visits.
Are there coverage limits (e.g., 6 months, one year, etc.)?
N/A
Is the coverage full, or is it 50%?
N/A
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
MediExcel Health Plan offers a weight loss program for members, where they may qualify for bariatric surgery after losing 10% of their initial body weight.
Supporting Collateral:
Please reference the bariatric surgery policy covered in pages 3 and 4 of this document.
Covered Medications:
Wegovy and Ozempic are available for purchase at the Excel Hospital’s Cosmetic & Medical Spa (however, these medications are not covered benefits under the MediExcel Health Plan).
- Wegovy: $165–$425 USD, depending on dosage
- Ozempic: $200–$275 USD, depending on dosage
For more information or to schedule a free consultation, contact Wellness Excel at (858) 374-3601.
Anyone may schedule an initial visit, during which the doctor will order the necessary tests to confirm eligibility.
If the patient qualifies, they will receive the medication that best aligns with their health needs.
The patient will participate in a medically supervised treatment plan, which includes personalized nutritional guidance.
At this time, the initial consultation is free.
Current as of 3/17/26
Do any of your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary?
Prominence Health Plan currently does not provide coverage for GLP 1 medications when used specifically for weight loss. To receive a GLP 1 through Prominence Health Plan, members must have a documented diagnosis of Type 2 diabetes and an approved prior authorization (PA).
Please refer to the formulary HERE for additional details.
Current as of 3/17/26
Do any of your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary?
GLP-1 coverage is evidence-based, with medical criteria and behavioral health modification requirements for weight-loss use.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently with receiving the weight loss drug?
Members must be enrolled in a Sharp Health Plan approved comprehensive weight loss program prior to or concurrent with receiving the weight loss drug and must meet Plan criteria for coverage when prescribed for treatment of morbid obesity. Members need to consult with their Primary Care Physician and have prior authorization submitted and reviewed for approval.
GLP-1 agents approved by the federal Food and Drug Administration (FDA) for the treatment of diabetes are covered under the Outpatient Prescription Drug benefit. Injectable GLP-1 agents approved by the FDA for the treatment of severe (Class III) obesity are covered under the medical benefit and are not covered under the Outpatient Prescription Drug benefit.
Formulary Exclusions:
Drugs that are prescribed solely for the purposes of losing weight, except when Medically Necessary for the treatment of morbid obesity or Mental Health and Substance Use Disorders.
Do you have any supporting documents, forms, flyers, marketing collateral, links, etc.?
Refer to the Member Handbook and Formulary. In addition, members can call into our Customer Service Team: 800-359-2002.
https://www.sharphealthplan.com/members/your-coverage-documents/member-handbooks
Covered Medications?
https://www.sharphealthplan.com/search-drug-list
Current as of 3/23/26
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Yes, the Sutter Health Plan member must obtain prior authorization for the necessary treatment of morbid obesity.
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
- A current body mass index (BMI) of greater than or equal to 40 kilograms per square meter OR
- A documented BMI of greater than or equal to 35 kilograms per square meter AND the patient has one or more comorbid conditions (cardiovascular disease, hypertension, dyslipidemia, diabetes, elevated waist circumference) OR other obesity-related medical condition (sleep apnea).
- AND all the following are met:
- There is documentation that the patient is actively enrolled in a weight loss program that involves a reduced-calorie diet and increased physical activity, adjunct to therapy.
- The patient’s age is appropriate according to the U.S. Food and Drug Administration (FDA) labeling for the requested drug.
- The patient is NOT receiving TWO drugs for weight loss at the same time.
- The patient does NOT have any contraindications to the requested drug.
- The requested drug is being used for an FDA-approved indication.
No, it is based on medical necessity.
Is the coverage full, or is it at 50%?
It depends on the Pharmacy benefits for the specific plan, and the Tier determined by the Sutter Health Plan Formulary.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Yes, documentation is required when the patient is actively enrolled in a weight loss program that involves a reduced-calorie diet and increased physical activity, adjunct to therapy.
- Beginning March 1, 2026, Sutter Health Plan will partner with Vida Health to provide members with personalized virtual health and wellness programs at no additional cost.
- Vida Health offers comprehensive support in areas such as weight loss, nutrition, fitness, stress management, and chronic condition care through an easy-to-use app featuring live coaching and clinical guidance.
- Members aged 18 and older who wish to receive coverage for weight loss medications must enroll in a Vida Health weight loss program and demonstrate monthly engagement.
- Click here to view the general Pharmacy Benefits Flyer. The EOCs for each plan also have related information under Pharmacy Exclusions and Limitations.
- For more information or to enroll beginning March 1, 2026, members can visit vida.com/sutterhealthplan or contact Vida Health Member Support at 833-732-2242.
Effective 10/15/2025, Sutter Health Plan moved Wegovy and Zepbound to Tier 4.
Updates:
- These updates apply only to FDA approved GLP 1/GIP medications prescribed for weight loss.
- Drugs prescribed solely for diabetes treatment are not affected by these changes.
- Sutter Health Plan will continue to cover weight loss medications for members diagnosed with morbid obesity.
- Members may be required to participate in a comprehensive weight management program either before starting therapy or while receiving treatment.
- Wegovy and Zepbound have been reclassified as non formulary and moved to Tier 4.
- These drugs will no longer appear on the Full Print Formulary.
- Tier 4 cost-sharing will apply for covered prescriptions.
- New authorization requests must follow the updated clinical criteria.
- Existing authorizations will stay in effect until their stated expiration dates.
Specialty Drug Classification:
- Wegovy, Zepbound, and Saxenda are now designated as specialty medications.
- Specialty status includes a 30 day supply limit per fill.
Pharmacy Access:
These medications will remain available at participating Sutter Health Plan network pharmacies.
Ozempic Clarification:
Under the Sutter Health Plan Formulary, Ozempic is not classified as a GLP 1 medication for weight loss. Its approved use is limited to the treatment of diabetes, and therefore, it cannot be authorized for weight loss purposes.
For a complete list of drugs on the Sutter Health Plan Formulary, go to: https://www.sutterhealthplan.org/pharmacy.
Current as of 3/19/26
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Yes, they are covered for UnitedHealthcare California small business fully insured plans.
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)? Are there coverage limits (e.g., 6 months, one year, etc.)?
- Body Mass Index (BMI) of greater than or equal to 30 kg/m2 or 27 kg/m2 with an obesity-related comorbidity.
- Motivation-based wellness program participation and prior authorization are required before drug coverage.
- There are no hard lifetime limits.
- Prior Authorization is typically approved for a defined duration (commonly 12 months) and must be re-reviewed.
- Supply Limits still apply per the Prescription Drug List (PDL).
- GLP-1 medications are covered under the PDL (generally Tier 3).
- Member’s cost share follows the Rx Benefit design, not a flat 50%.
Motivation-based wellness program participation and Prior Authorization are required before drug coverage.
Supporting Collateral:
N/A
Covered Medications:
Please refer to the CA SB PDL lists for the GLP-1 medications covered. They all fall under Tier 3 of the member’s Rx plan benefit.
NOTED:
- Prior Authorization required.
- May be covered under the medical benefit with prior authorization for HMO plans.
- Supply Limits as outlined in the PDL.
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
- Yes, all Western Health Advantage plans will cover GLP-1s for weight management as required by state requirements when medically necessary, as defined by a body mass index (BMI) of > 40. GLP-1s for other indications (metabolic dysfunction-associated steatohepatitis (MASH), Obstructive sleep apnea (OSA), and reduce the risk of major adverse cardiovascular events) are covered when specific criteria are met.
- All weight loss products (oral and GLP1s) are not on formulary but can be accessed if approved through the prior authorization (PA) or non-formulary (NF) exceptions process.
Yes, for weight management, BMI > 40. BMI < 40 is not considered medically necessary.
For the most up-to-date clinical criteria for other indications, please visit the Western Health Advantage website for PA and NF Criteria.
Are there coverage limits (e.g., 6 months, one year, etc.)?
Yes, all approvals will be 6 months (initial and renewals) with ongoing coverage requiring updated chart notes that document all reauthorization criteria points as found on the Western Health Advantage website (WHA PA and NF Criteria).
Is the coverage full, or is it 50%?
- Weight loss drugs are not on formulary, so when approved through the PA/NF process, they will default to the highest applicable tier cost share.
- Diabetic GLP1s are covered on tier 2 with a PA. Members should refer to their copayment summary for further details.
Not currently, but Western Health Advantage is exploring that option to expand.
Supporting Collateral:
The Western Health Advantage Formulary lookup tool can be used to see what drugs are and are not on formulary.
Covered Medications:
- Dulaglutide: Brand name Trulicity
- FDA approved for Type 2 Diabetes Mellitus (T2DM) and requires a PA with chart notes documenting diagnosis (confirmed with lab values) and trial and failure with 30 days of metformin or another antidiabetic drug.
- Exenatide: Brand names Byetta, Bydureon, and Exenatide
- Byetta, Byduren: Same as above.
- Brand Exenatide is not on the formulary, but can be accessed through the NF exceptions pathway: criteria same as above + trial and failure with three preferred products (Ozempic, Rybelsus, Trulicity, Byetta, Bydureon, or Mounjaro)
- Liraglutide: Brand names Victoza and Saxenda
- Brand Victoza is non-preferred and requires the same criteria as above + trial and failure with generic liraglutide and two preferred products (Ozempic, Rybelsus, Trulicity, Byetta, Bydureon, or Mounjaro). Saxenda is for weight loss and is held to the criteria mentioned in the third column.
- Lixisenatide: Brand Name Adlyxin
- This drug is no longer available in the United States. Soliqua (insulin glargine with lixisendatide) is available without a PA.
- Semaglutide: Brand names Ozempic, Wegovy, and Rybelsus
- Ozempic and Rybelsus are FDA-approved for T2DM and are held to the same criteria as Trulicity. Wegovy is for weight loss and is held to the criteria mentioned in the third column.
- Tirzepatide: Brand names Mounjaro and Zepbound
- Mounjaro is only FDA-approved for T2DM and is held to the same criteria as Trulicity. Zepbound is for weight loss and is held to the criteria mentioned in the third column.
Carrier Commission Disclaimer
The information herein was collected from sources deemed reliable including information from various carriers. We have not verified nor can we guarantee the accuracy, timeliness or completeness of such information, which is provided on an “AS-IS” basis. It is solely your responsibility to verify this information before making decisions or incurring costs based on such information. Further, you should contact the carrier for full details regarding the products and programs contained herein.Most Recent Articles
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