How do you get Zepbound or Wegovy covered by insurance? Prior authorization, step by step
What a plan checks before it pays, one large pharmacy benefit manager’s published criteria, the renewal test and your appeal rights. Federal rules, not one insurer’s promises.
Written for the United States. Reading from India? India version
First, your plan has to cover GLP‑1s for weight at all; many employers don’t. If it does, your prescriber sends a prior authorization with your BMI, conditions and weight history. One large benefit manager also asks for 6 months in a weight program, then at least 5% weight loss to renew.
Key takeaways
- Employer coverage of GLP‑1s for weight loss is optional: KFF found 16% of firms with 200 to 999 workers covered them in 2025, and 43% of firms with 5,000 or more.1
- A prior authorization is advance approval from your plan before it pays for a medicine, sent by your prescriber with records such as your BMI and weight-related conditions.2
- One large pharmacy benefit manager’s published Zepbound criteria ask for 6 months in a weight management program and a BMI of 30, or 27 with a weight-related condition.2
- The same criteria renew coverage after at least 3 months on a stable maintenance dose only if you have lost at least 5% of your starting weight, or kept that loss.2
- If a plan says no, federal rules for most plans give you 180 days to file an internal appeal and then a right to an independent external review.3,4
- Every plan sets its own rules. The criteria below are one published example, not your plan’s rules. Your plan’s documents decide.
- This post explains a process. It doesn’t tell you whether you qualify: your plan and your prescriber decide that.
- Wegovy and Zepbound need a prescription, and they carry real risks: see our side effects guide.
On this page
Does your plan cover GLP‑1s for weight at all?
Check this first: coverage of GLP‑1s for weight is an optional extra that many employers leave out, especially smaller ones.1
KFF’s 2025 survey of employers found that covering GLP‑1s mainly for weight loss rises with company size.1
Of the firms that do cover them, 34% require you to see a dietitian, case manager or therapist, or join a lifestyle program.1 Call the number on your insurance card and ask three things:
- Does my plan cover GLP‑1 medicines for weight management?
- Which brands are on the formulary (the plan’s list of covered drugs), and which are preferred?
- What does the prior authorization need?
Formularies change. One of the largest pharmacy benefit managers (PBMs), the companies that run drug benefits for plans, made Zepbound a preferred option again from October 1, 2026. Employers using its lists can still customize them.5
What does a prior authorization ask for?
Usually proof of your BMI and any weight-related condition, and sometimes proof of a past weight program; one large PBM’s published criteria show the pattern.2
A pharmacy benefit manager publishes the criteria it uses for Zepbound and Mounjaro. For weight management, it asks for all of these, with documents:2
- A weight program first: at least 6 months in a program that covers behavior change, a reduced-calorie diet and more physical activity, with follow-up.
- A starting BMI of 30 or more, or 27 or more with at least one weight-related condition, such as high blood pressure, type 2 diabetes or high cholesterol.
- Your starting BMI before any earlier weight-loss drug, if you are switching.
The BMI part matches the FDA labels. Zepbound is approved for adults with obesity, or with overweight and at least one weight-related condition; its trials used a BMI of 30, or 27 with a condition.6 The 6-month program is the payer’s own rule, not the label’s.
For sleep apnea, the same document asks for a sleep test showing at least 15 breathing pauses an hour, and a BMI of 30 or more: see Zepbound for sleep apnea.2
What are the steps from prescription to pharmacy?
Your prescriber sends the request with your records, the plan decides, and approval lasts a set time; under the published criteria above, 8 months at first for weight.2
- 1Gather your records. Weight and height measured in the clinic, your conditions, past programs and any earlier weight medicines.
- 2Your prescriber sends the request to the plan or its PBM, usually through an electronic form.
- 3The plan decides. If it approves, the approval runs for a set time. In the criteria above: 8 months at first for weight, then 12 months at a time.2
- 4Fill the prescription. Plans often limit how much you can get at once. The same criteria allow 4 pens per 28 days.2
- 5Renew before it lapses. Expect to show your weight change: see the next section.
Once approved, the makers’ savings cards can lower your copay. Novo Nordisk’s Wegovy card lets you pay “as little as $25”, with savings capped at $100 a month.7 Lilly’s Zepbound card works the same way, up to $1,300 a year.8 Neither card is for Medicare or Medicaid.7,8
Build your own list of questions to take to your doctor. No sign-up.
What does it take to renew coverage?
Under one large PBM’s criteria, at least 3 months on a stable maintenance dose and at least 5% of your starting weight lost, or that loss kept.2
For someone who started at 220 lb (100 kg), 5% is 11 lb (5 kg). The FDA labels for Wegovy and Zepbound don’t set a percentage at which to stop.9,6 The 5% test is the payer’s rule.
In the trials, most people passed that mark. In the main Zepbound trial for weight, 85 to 91 in 100 people lost at least 5% by week 72, against 35 in 100 on placebo (a dummy injection).6 In the main Wegovy trial, 84 in 100 did, against 31 in 100 on placebo.9 Put the other way, about 9 to 16 in 100 people on the medicine did not.
- Stomach effects. In the main trials, about 44 in 100 people on Wegovy 2.4 mg injection felt sick (nausea), against about 16 in 100 on a dummy injection (placebo);9 about 25 to 29 in 100 people on Zepbound felt sick, against about 8 in 100 on a dummy injection.6 It mostly comes while the dose goes up.
- Gallstones were reported in 16 in 1,000 people on Wegovy injection, against 7 in 1,000 on placebo;9 11 in 1,000 on Zepbound, against 10 in 1,000 on placebo, with gallbladder inflammation in 7 in 1,000 against 2 in 1,000.6
- Pancreatitis (an inflamed pancreas): severe stomach pain that won’t go away and may spread to the back. The labels say to stop the medicine if it is suspected.9,6
- Thyroid warning. The labels carry a boxed warning: these medicines are not for people with a personal or family history of medullary thyroid cancer (MTC) or MEN 2, a rare inherited condition that causes gland tumors.9,6
- Dehydration from vomiting or diarrhea can harm the kidneys. Tell the team before any surgery or sedation, because a slower-emptying stomach raises the risk of breathing in food or fluid.9,6
- Pregnancy. The Wegovy label says to stop at least 2 months before a planned pregnancy;9 Zepbound can make birth-control pills less reliable for about 4 weeks after starting and after each dose step.6
What can you do if the plan says no?
Ask why in writing, fix what was missing, and appeal: federal rules give you 180 days for an internal appeal and then the right to an independent review.3,4
A denial often means a document was missing, such as proof of a program or a recent weight. A corrected request may be enough. If not, HealthCare.gov sets out your rights:
- Internal appeal: file within 180 days of the denial notice. For a medicine you haven’t received yet, the plan must decide within 30 days.3
- Urgent cases: a decision as fast as your condition needs, and no later than 4 business days.3
- External review: if the plan still says no, an independent third party can review it.4
An appeal can’t make a plan cover something it excludes. If weight-loss drugs aren’t a benefit at all, the cash routes are in GLP‑1 costs without insurance. On Medicare, see the $50 GLP‑1 Bridge; on Medicaid, which states cover them.
Questions people ask
Why does my insurance cover Ozempic but not Wegovy?
Plans often treat diabetes and weight differently. Ozempic is approved for type 2 diabetes; Wegovy is approved for weight and heart risk, and covering weight-loss drugs is optional for employers.11,9,1
How long does a prior authorization last?
It depends on the plan. In one large PBM’s published criteria, approval for weight lasts 8 months at first, then 12 months at a time.2
Do I need to try diet and exercise first?
Some plans ask for it. One large PBM’s criteria require 6 months in a weight management program before drug therapy. 34% of employers that cover these drugs require a dietitian, case manager or lifestyle program.2,1
Can I use the savings card if my PA is denied?
Lilly’s and Novo Nordisk’s $25 offers are for people whose plan covers the drug. Without coverage, the makers’ self-pay prices apply.8,7
How long do I have to appeal a denial?
For most plans, 180 days from the denial notice for an internal appeal, then you can ask for an external review.3,4
How we researched this
We used KFF’s 2025 employer survey for coverage rates and one large pharmacy benefit manager’s published prior authorization criteria for tirzepatide as a worked example. We did not collect other insurers’ criteria, which differ.1,2
Appeal rights come from HealthCare.gov. Trial figures come from the US labels for Wegovy and Zepbound. All sources were checked on October 12, 2026.3,9,6
Before you move on
- Ask your plan whether GLP‑1s for weight are covered at all.
- Ask which brand is preferred.
- Collect proof of any weight program you’ve done.
- Diary the renewal date and the 5% test.
- Appeal in writing within 180 days if denied.
More from the US blog
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Sources
- KFF. 2025 Employer Health Benefits Survey, section on GLP-1 coverage for weight loss. October 22, 2025. Link
- CVS Caremark. Tirzepatide prior authorization criteria with quantity limit, reference 6947-C (pharmacy benefit manager criteria document). Checked Oct 12, 2026. Link
- HealthCare.gov. Internal appeals. Link
- HealthCare.gov. Appealing a health plan decision. Link
- CVS Health. CVS Caremark delivers affordability and access to GLP-1 weight management medications with expanded coverage options. News release, May 28, 2026. Link
- Eli Lilly. Zepbound (tirzepatide): US prescribing information. Revised 8/2026. Link
- Novo Nordisk. Price your Wegovy (NovoCare): self-pay prices by dose, new-patient offer and savings-card terms. Checked Oct 12, 2026. Link
- Eli Lilly. Zepbound coverage and savings, for health care providers. Checked Oct 12, 2026. Link
- Novo Nordisk. Wegovy (semaglutide) injection and tablets: US prescribing information. Revised 06/2026. Link
- Poison Control (National Capital Poison Center). Poison help line 1-800-222-1222. Link
- Novo Nordisk. Ozempic (semaglutide) injection: US prescribing information. Revised 05/2026. Link
Last checked Oct 12, 2026 · Next review due Apr 12, 2027 · Report an error
How this post was made. Written by the GLP Guidebook team from the sources above. It’s general information, not medical advice. Talk to your doctor, pharmacist or prescriber before starting, stopping or changing any medicine. We don’t sell, prescribe or recommend any brand or provider. How we write