GLP-1 and GIP/GLP-1 medications — Wegovy (semaglutide) and Zepbound (tirzepatide) for weight loss, with Saxenda (liraglutide) as an older option — are the most-requested and most-denied drugs in the country right now. The denials aren't random. They follow a three-gate logic, and understanding the gates is the difference between an approval and a months-long appeal.
This is the one almost nobody checks first, and it's the one that ends most requests:
The fastest way to settle Gate 1 is to look up the exact drug on your plan's formulary — that's what our Drug Lookup does.
If your plan covers the benefit, the clinical bar is fairly standard across commercial insurers and follows the drug labels: a BMI of 30 or higher, or 27 or higher with a weight-related condition (type 2 diabetes, high blood pressure, high cholesterol, or sleep apnea). The BMI threshold isn't where insurers mainly differ — the next gate is.
This is the gate that quietly decides most cases. Before approving the drug, insurers want to see a documented, medically-supervised weight-management program — diet, exercise, and behavioral support — already attempted. How long it has to be, and how strict the documentation, differs:
| Insurer | BMI bar | Required prior program | Notes |
|---|---|---|---|
| Cigna | ≥30 (or ≥27 + condition) | 3 months supervised | Continuation needs ≥5% weight loss |
| Aetna | ≥30 (or ≥27 + condition) | 6 months supervised | Continuation needs ≥5% weight loss |
| Anthem / Elevance | ≥30 (or ≥27 + condition) | 6 months + quantified diet/exercise targets + failure to reach 5% on lifestyle alone | The strictest documentation bar |
| UnitedHealthcare | ≥30 (or ≥27 + condition) | Documented program; step-therapy applies | Per UHC's own PA criteria |
| Medicare | Not covered for weight loss (federal statute) | Covered only via a separate indication — see below | |
| Medicaid | Varies by state — some cover anti-obesity drugs, many don't | ||
Read the Anthem row carefully: it's not enough to have tried diet and exercise — Anthem wants the chart to show the specific targets and that lifestyle alone failed to reach 5% weight loss. Walking in without that documentation is the most common reason an otherwise-qualified Anthem patient gets denied.
Even when the weight-loss benefit is excluded, the same molecules are often covered under a different FDA-approved indication that doesn't touch the weight-loss benefit at all:
So a Medicare patient with obesity and sleep apnea may get Zepbound covered under the OSA indication, even though weight loss is statutorily excluded. Matching the drug to the indication your plan does cover is often the whole game.
Pick your drug, your indication, and your insurer, and see exactly where you stand — including whether a different covered indication is the faster path.
Check my GLP-1 coverageNo. Medicare Part D is barred by federal law from covering drugs used for weight loss, so it will deny Wegovy or Zepbound for obesity regardless of BMI. It can cover them only under a separate approved indication — Wegovy for cardiovascular risk reduction in people with established heart disease, or Zepbound for moderate-to-severe obstructive sleep apnea with obesity.
Only if your specific plan includes a weight-loss (anti-obesity) drug benefit — many employer plans don't, and some dropped it for 2026. If it does, you'll typically need a BMI of 30 or higher (or 27 with a weight-related condition) plus a documented supervised weight-management program of several months. The quickest way to know is to look up Zepbound on your plan's formulary.
The most common reasons, in order: your plan doesn't cover weight-loss drugs at all; you didn't have a documented supervised diet-and-exercise program before the drug; you were below the BMI threshold; or you hadn't met a step-therapy requirement. The supervised-program gap is the single most frequent fixable reason — get the program's dates, targets, and results into the chart.
It depends on the insurer: Cigna generally wants 3 months of a documented medically-supervised weight-management program, while Aetna and Anthem want 6 months — and Anthem also wants quantified diet and exercise targets plus documentation that lifestyle alone didn't achieve 5% weight loss.
Yes, potentially. Zepbound (tirzepatide) is FDA-approved for moderate-to-severe obstructive sleep apnea in adults with obesity, and that indication is covered with prior authorization independent of whether your plan covers weight-loss drugs. You'll need a sleep study documenting the OSA. This is often the covered path for patients whose plan excludes anti-obesity drugs.
For the weight-loss indication, most commercial plans follow the drug labels: a BMI of 30 or higher, or 27 or higher with a weight-related condition such as type 2 diabetes, high blood pressure, high cholesterol, or sleep apnea.
They're different molecules with different approved indications, which changes the covered path. Wegovy (semaglutide) is covered for weight loss, for cardiovascular risk reduction with established heart disease, and for MASH liver disease. Zepbound (tirzepatide) is covered for weight loss and for obstructive sleep apnea. Matching the drug to the indication your plan covers is what gets it approved.
For the weight-loss indication, metformin isn't usually the gate — the supervised program is. But for the type 2 diabetes indication, insurers generally want a documented trial of, or contraindication to, metformin before covering a GLP-1, unless you have established cardiovascular disease.
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