Answer
The short answer
Neither yes nor no, and the difference decides what you do. Prior authorization means the drug is on your formulary behind a gate with written criteria you can demand. An exclusion means it is not there at all.
A gate is a condition. The drug is a benefit under your plan, and the plan wants specific things documented before it pays. There is a criteria document, there is a decision, and there is an appeal if the decision goes against you.
An exclusion is a different animal. The plan does not cover that use at all, so there is no criterion to satisfy — which is why an exclusion and a prior authorization requirement should never be described with the same word. If your benefit materials exclude weight-loss drugs, meeting a body mass index threshold changes nothing, because nobody is asking about your body mass index.
Read your notice for which one you are looking at. The letter has to reference the specific plan provisions the determination is based on, and that reference is how you tell.
There is a clock on them, and most people do not know it exists. For a request for care you have not received yet, the plan has to answer within a set period after receiving the claim, extendable once and only for reasons beyond its control, and it has to tell you before the first period runs out that it is extending and when it now expects to decide.
If the delay is because you have not sent something, the notice has to describe specifically what is needed, and you get a minimum period to supply it. The plan's clock pauses while it waits on you and restarts when you answer.
Urgent requests run on a much shorter clock, and your prescriber can put you on it: any claim a physician with knowledge of your condition determines is a claim involving urgent care has to be treated as one.
The regulation's free-of-charge document rights attach to the determination and to the appeal, not to the moment you first wonder. That is the honest answer, and it is worth stating rather than implying you have a right you do not.
In practice the criteria are usually obtainable anyway, because insurers publish coverage policies and member services can send the one for your plan. Ask for the prior authorization policy for the named drug rather than asking whether the drug is covered — the second question gets you a call-center answer and the first gets you a document.
For this drug class, three things recur across published policies: a documented trial of behavioral and dietary change with a minimum duration, a body mass index floor which may be lower where a weight-related condition is present, and a measured weight-loss result required to keep the authorization at renewal.
The numbers are not the same everywhere and are not even the same within one insurer, because employers buy different benefit options. Do not assume the figure you read on a general page is the figure in your plan's document.
Missing it has consequences for them rather than for you. Where a plan fails to establish or follow claims procedures consistent with the rules, you are deemed to have exhausted its internal remedies. For health coverage a failure to adhere strictly to the internal appeal requirements deems the process exhausted and lets you initiate an external review, subject to a narrow exception for minor, harmless, good-faith lapses that are not part of a pattern.
Your plan also cannot make you appeal indefinitely before going to court: its procedures must not require more than two appeals of an adverse determination before you bring a civil action. And it cannot charge you for the privilege — requiring a fee as a condition of making a claim or appealing one is treated as unduly inhibiting the process.
What to say on the phone
I am asking about a prior authorization for [drug name]. Please tell me whether this drug is excluded from my plan or covered subject to prior authorization — those are different and I need to know which. Please send me the prior authorization policy for this drug, confirm the date you received the request, and tell me the date your decision is due.
Get the received date in particular. Every clock on the plan's side runs from it, and it is the one fact a later appeal turns on that nobody writes down.
If something here decides anything for you, read the source rather than our summary of it. These are the documents we opened, and the month we opened them.
There is a clock on a prior authorization request, and one extension. For a pre-service claim the plan must notify you "within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim by the plan. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 15-day period, of the circumstances requiring the extension." Where the delay is because information is missing, "the notice of extension shall specifically describe the required information, and the claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information."
29 CFR §2560.503-1(f)(2)(iii)(A), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
An incomplete filing still starts the clock, and the clock pauses only while the plan is waiting on you. The regulation states "the period of time within which a benefit determination is required to be made shall begin at the time a claim is filed in accordance with the reasonable procedures of a plan, without regard to whether all the information necessary to make a benefit determination accompanies the filing," and that where an extension is due to your failure to submit information, "the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds."
29 CFR §2560.503-1(f)(4), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
Urgent requests run on a far shorter clock, and your prescriber can put you on it. The plan must decide "as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim," and separately: "Any claim that a physician with knowledge of the claimant's medical condition determines is a 'claim involving urgent care'... shall be treated as a 'claim involving urgent care' for purposes of this section."
29 CFR §2560.503-1(f)(2)(i) and (m)(1)(iii), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
The notice has to point at the plan language it relied on, which is how you tell a gate from an exclusion. It must contain "Reference to the specific plan provisions on which the determination is based," and "A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary."
29 CFR §2560.503-1(g)(1)(ii) and (g)(1)(iii), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
Your plan cannot make you appeal forever, and cannot charge you to try. Its procedures must not contain any provision, and must not be administered in a way, that "requires a claimant to file more than two appeals of an adverse benefit determination prior to bringing a civil action under section 502(a) of the Act." And "a provision or practice that requires payment of a fee or costs as a condition to making a claim or to appealing an adverse benefit determination would be considered to unduly inhibit the initiation and processing of claims for benefits."
29 CFR §2560.503-1(c)(2) and (b)(3), Electronic Code of Federal Regulations, effective August 2026 · source · read August 2026
Cigna's published criteria require a trial of behavioral modification and dietary restriction for at least three months, plus a baseline BMI of 30 or more, or 27 or more with a weight-related condition. Continuing coverage requires documented weight loss: at least 5% of baseline for Wegovy, Zepbound and Foundayo, and at least 4% for Saxenda.
Cigna, effective revised through April 2026 · source · read August 2026
Do not assume one BMI number applies to you. The same insurer publishes different floors for different employer benefit options: Cigna publishes both a 30 and a 32 threshold, and UnitedHealthcare's document contains a stricter tier at 40.
Cigna, effective April 2026 · source · read August 2026
American GLP is not a law firm, an insurer, a government office or a clinician, and nothing here is legal or medical advice. This page describes what published rules say. Your own plan documents and your own notice govern your case, and rules change — check the sources before you act.