Weight Loss Drugs (GLP-1) Insurance Coverage

Weight Loss Drugs (GLP-1) Insurance Coverage Breakdown By Carrier

Updated on: May 01, 2026 | By Word & Brown General Agency | California & Nevada

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.

Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?

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.

Are there coverage limits (e.g., 6 months, one year, etc.)?

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?

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
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

Current as of 3/17/26

(California)
As of January 1, 2025, all GLP-1 drugs have been reclassified from Tier 3 non-formulary to Tier 4 specialty drugs. They remain non-formulary and still require prior authorization. Previously, when these drugs gained popularity, Anthem provided coverage by overriding the plan exclusion. However, starting around October 2024, claims began to be denied correctly as an exclusion.

Despite some GLP-1 drugs being used for conditions other than obesity and weight loss, authorization is still required. The clinical criteria for medical review are attached.

Current as of 5/1/26

(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

Current as of 3/17/26

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.

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, 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.

Do you have any supporting documents, forms, flyers, marketing collateral, links, etc.?

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.

Current as of 3/17/26

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. Health Net applies specific clinical criteria for approval of medications indicated for weight management.

BMI Requirements:

Adults (Small Group):
- BMI ≥ 30 kg/m²; or
- BMI ≥ 27 kg/m² with at least one indicator of increased cardiovascular risk (e.g., coronary heart disease, hypertension, dyslipidemia, diabetes, elevated waist circumference), or another obesity-related medical condition (e.g., sleep apnea).
Pediatrics (Wegovy only): Ages 12–17: BMI ≥ 95th percentile standardized for age and sex.
Zepbound is indicated for adults only.
For indications other than weight loss, Health Net follows FDA-approved labeling for BMI requirements.

Additional Clinical Criteria:

The medication must not be prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonists.
For members with concurrent type 2 diabetes, documentation must show ≥ 3 consecutive months of optimal standard of care therapy with all of the following (unless contraindicated or not tolerated):
- Ozempic® or Rybelsus®
- Trulicity®
- Liraglutide (generic Victoza®)
- Mounjaro®
Documentation of participation in a Health Net–approved weight loss program (e.g., Weight Watchers, Active&Fit) or a prescriber-recommended plan that includes reduced caloric intake, increased physical activity, and lifestyle modification.
Documentation of current height and body weight to calculate BMI.
Planned follow-up visits required to assess adherence and clinical response.

Approval Duration and Continuation Criteria:

Initial and continuation approval: 16 weeks (oral and injectable).
Demonstrated positive response defined as ≥ 5% reduction from baseline body weight (adults) or baseline BMI (pediatrics), or maintenance of weight loss with continued participation in a weight management program.

Are there coverage limits (e.g., 6 months, one year, etc.)?

Initial and continuation approval: 16 weeks (oral and injectable).
Demonstrated positive response defined as ≥ 5% reduction from baseline body weight (adults) or baseline BMI (pediatrics), or maintenance of weight loss with continued participation in a weight management program that includes lifestyle modification, exercise, and reduced calorie diet.

Is the coverage full or is it at 50%?

Member cost-sharing will be capped at $250.

Are members required to be enrolled in a comprehensive weight loss program prior to or concurrently with receiving the medication?

Yes, this program requires participation in a lifestyle modification /weight loss program that includes a lifestyle change, a reduced calorie diet and increased physical activity before requesting prior authorization. Examples of this are Weight Watchers, Active&Fit etc.

Current as of 5/1/26

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.)?

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 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?

Doctor will review the member’s medical history, learn more about their goals, and discuss where they are in their 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 member’s 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

Do you have any supporting documents, forms, flyers, marketing collateral, links, etc.?

Yes.
https://healthy.kaiserpermanente.org/health-wellness/weight-management?kp_shortcut_referrer=kp.org/weightmanagement

Which specific weight loss medications are covered under your plans?

Based on the formulary posted on KP.org – Ozempic.

Current as of 5/1/26

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

Medical evaluation and supervision are included.

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

Sharp Health Plan does not have any specific flyers or additional materials outlining coverage details. These medications are covered based on medical necessity and require prior authorization from the member’s physician. Sharp Health Plan strongly encourage members to consult with their physician to determine if they are appropriate candidates for these medications and to discuss whether approval is likely. Once authorization is granted, the member’s plan copay will apply, according to their benefits.

Current as of 5/1/26

Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?

Yes, Sutter Health Plan has and will continue to cover drugs that are medically necessary for treatment of morbid obesity.

Are there specific clinical criteria required for approval (e.g., BMI thresholds, sustained weight requirements, step therapy such as participation in a weight management program)?

When a person’s body mass index (BMI) is 40 kg/m2 or greater. Members must enroll in Vida and complete 6 months of active engagement before coverage begins. After coverage starts, monthly engagement is required to continue coverage.

Are there coverage limits (e.g., 6 months, one year, lifetime maximums, etc.)?

Based on medical Necessity.

Is coverage provided at 100%, or is there member cost-sharing (e.g., 50%)?

As of Oct. 15, 2025, Wegovy and Zepbound are now designated as nonformulary and moved to Tier 4. Like other nonformulary drugs, Wegovy and Zepbound are not listed in the Sutter Health Plan Full Print Formulary. A member using Wegovy or Zepbound for any indication will have a Tier 4 cost share. A member will pay the Tier 4 cost share for these drugs, whether they were prescribed for weight management or obstructive sleep apnea, for example.

Are members required to be enrolled in a comprehensive weight loss program prior to or concurrently with receiving the medication?

Yes, Vida and complete 6 months of active engagement before coverage begins.

Do you have any supporting materials you can share (e.g., forms, flyers, marketing collateral, or helpful links)?

Yes, click here.

Which specific weight loss medications are covered under your plans?

All weight loss medication requires a prior authorization and based medical necessity.

Additional info:

Previously approved for a weight loss drug (incl: PA approved before 3/1/2026): Member is not required to enroll in Vida or complete 6 months of engagement until the current prior authorization expires.

Once the PA expires, the member must enroll in Vida and meet active monthly engagement requirements to continue coverage.

Current as of 5/1/26

Do any of your plans cover weight loss drugs (GLP 1s) when deemed medically necessary?

Yes, covered for CA Fully Insured Groups only.

Are there specific clinical criteria required for approval (e.g., BMI thresholds, sustained weight requirements, step therapy such as participation in a weight management program)?

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.

Are there coverage limits (e.g., 6 months, one year, lifetime maximums, etc.)?

Prior authorization is typically approved for a defined duration (commonly 12 months) and must be re-reviewed.

Is coverage provided at 100%, or is there member cost-sharing (e.g., 50%)?

GLP-1 medications covered under the PDL (generally Tier 3).

Members cost share follows the Rx Benefit design, not a flat 50%.

Are members required to be enrolled in a comprehensive weight loss program prior to or concurrently with receiving the medication?

Motivation-based wellness program participation and prior authorization are required before drug coverage.

Do you have any supporting materials you can share (e.g., forms, flyers, marketing collateral, or helpful links)?

Not applicable.

Which specific weight loss medications are covered under your plans?

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:

PA (prior authorization) required.
May be covered under the medical benefit with prior authorization for HMO plans.
SL (supply limits) as outlined in the PDL.

Current as of 5/1/26

Do any of your plans cover weight loss drugs (GLP 1s) when deemed medically necessary?

Yes, all 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) when specific criteria are met.

All weight loss products (oral and GLP-1s) are not on formulary but can be accessed if approved through the prior authorization (PA) or non-formulary (NF) exceptions process.

Are there specific clinical criteria required for approval (e.g., BMI thresholds, sustained weight requirements, step therapy such as participation in a weight management program)?

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, lifetime maximums, 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 coverage provided at 100%, or is there member cost-sharing (e.g., 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.

Are members required to be enrolled in a comprehensive weight loss program prior to or concurrently with receiving the medication?

Not currently, but Western Health Advantage is exploring that option to expand.

Do you have any supporting materials you can share (e.g., forms, flyers, marketing collateral, or helpful links)?

Formulary lookup tool can be used to see what drugs are and are not on formulary.

Which specific weight loss medications are covered under your plans?

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 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 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.

Current as of 5/1/26

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.

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