Does a weight-loss exclusion rule out every use?

The Medicaid drug statute lets a state exclude a list of drugs, and the first item is: "The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain." The Part D definition borrows the list: a Part D drug "does not include drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under section 1396r–8(d)(2)".

42 U.S.C. §1396r-8(d)(2)(A) and §1395w-102(e)(2)(A), Legal Information Institute text · source · §1395w-102

CMS, March 20, 2024, "Part D Coverage of Anti-Obesity Medications with Medically Accepted Indications": "CMS is clarifying that AOMs that receive FDA approval for an additional medically accepted indication … can be considered a Part D drug for that specific use." A GLP-1 approved "for chronic weight management alone would not be considered a Part D drug," but if it is also approved to treat diabetes or to reduce major cardiovascular events "then it would be considered a Part D drug for those specific uses only." "Part D sponsors may consider using prior authorization for these products to ensure they are being used for a medically accepted indication."

Centers for Medicare & Medicaid Services, HPMS memorandum, effective March 2024 · source

CMS: "Type 2 diabetes, moderate to severe obstructive sleep apnea, and noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver scarring (fibrosis) indications are eligible for Part D coverage. Beneficiaries with these diagnoses are eligible to receive GLP-1s through their Part D plan and therefore are ineligible to receive them through the Medicare GLP-1 Bridge." A prescription "to reduce the risk of major adverse cardiovascular events … should be routed to the Part D plan." For these uses, "Part D plan sponsors must continue to follow their existing formulary exception processes."

Centers for Medicare & Medicaid Services, Medicare GLP-1 Bridge: information for Part D plans, effective August 2026 · source

FDA, March 8, 2024: "the U.S. Food and Drug Administration approved a new indication for use for Wegovy (semaglutide) injection to reduce the risk of cardiovascular death, heart attack and stroke in adults with cardiovascular disease and either obesity or overweight."

US Food and Drug Administration, news release, effective March 2024 · source

FDA, December 20, 2024: "the U.S. Food and Drug Administration approved Zepbound (tirzepatide) for the treatment of moderate to severe obstructive sleep apnea (OSA) in adults with obesity, to be used in combination with a reduced-calorie diet and increased physical activity." The agency called it "the first drug treatment option for certain patients with obstructive sleep apnea."

US Food and Drug Administration, news release, effective December 2024 · source

Wegovy's label lists three uses for the injection: "to reduce the risk of major adverse cardiovascular (CV) events … in adults with established CV disease and either obesity or overweight"; "to reduce excess body weight and maintain weight reduction long term"; and "for the treatment of noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) … with moderate to advanced liver fibrosis" in adults, under accelerated approval. The tablets carry the cardiovascular and weight uses, not MASH. Novo Nordisk announced the MASH approval on August 15, 2025.

DailyMed (National Library of Medicine), Wegovy prescribing information, and Novo Nordisk news release, effective June 2026 · source

A separate program exists for plans that did not buy it, and it says why: "Medications for the purpose of weight loss are typically a benefit exclusion. The program allows for coverage of Wegovy injection or tablet for the cardiovascular risk reduction indication and Wegovy injection for MASH." It will not approve Wegovy for weight loss, because that is the thing those plans exclude.

UnitedHealthcare, Clinical Pharmacy Programs, "Prior Authorization/Non-Formulary – Wegovy (semaglutide) injection, Wegovy (semaglutide) tablets – Cardiovascular Risk Reduction and MASH Only" (2026 P 1445-4), effective May 2026 · source

Zepbound has the same arrangement through a different door. Its non-formulary program repeats that "Medications for the purpose of weight loss are typically a benefit exclusion," and then states: "The program allows for coverage of Zepbound for obesity with obstructive sleep apnea." It requires a sleep study, a BMI of at least 30, and either continued symptoms despite adherent positive airway pressure therapy or a reason you cannot use it.

UnitedHealthcare, Clinical Pharmacy Programs, "Prior Authorization/Non-Formulary – Zepbound (tirzepatide) – Obstructive Sleep Apnea Only" (2026 P 1475-3), effective September 2026 · source

Cigna's benefit-exclusion override policy for GLP-1s (IP0621, effective April 30, 2026) opens: "Weight loss medications are specifically excluded under many benefit plans", then says it "authorizes coverage non-weight loss based on FDA-approved indications as applicable." Its sleep apnea criteria approve Zepbound for one year for a patient 18 or older with a baseline BMI of at least 30 and "a sleep study" showing moderate to severe obstructive sleep apnea with "an apnea-hypopnea index ≥ 15 events per hour", and not central sleep apnea. Renewal after a year requires having "lost ≥ 10% of baseline body weight".

Cigna Healthcare, Drug Coverage Policy IP0621, "Weight Loss – Glucagon-Like Peptide-1 Agonists BMI ≥ 32" (Benefit Exclusion Overrides), effective April 2026 · source

Aetna states when its own criteria stop applying. Its weight reduction policy notes that "Many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan," and continues: "The medical necessity criteria set forth below do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control. Under these plans, claims for weight loss drugs will be denied based on this exclusion." The policy's history records a last review of 03/10/2026.

Aetna, Medical Clinical Policy Bulletin 0039, "Weight Reduction Programs and Devices", effective February 2000 · source

Independence Blue Cross: "On May 1, 2025, Independence Blue Cross (IBX) Select Drug Program® and Value Formularies ended coverage of Zepbound (tirzepatide) for the treatment of moderate to severe obstructive sleep apnea (OSA)." "This coverage change aligns with IBX's recent update to exclude coverage of weight loss drugs."

Independence Blue Cross, provider news 25-0038, effective May 2025 · source

CMS: the Bridge gives access "between July 1, 2026, and December 31, 2027." "Eligible beneficiaries will have a $50 copay … the Part D deductible will not apply, no part of the $50 copay counts towards the beneficiary's TrOOP costs, and there is no low-income subsidy (LIS) provided for LIS beneficiaries."

Centers for Medicare & Medicaid Services, Medicare GLP-1 Bridge, effective July 2026 · source

Zepbound and Saxenda came off the Contract Drugs List on January 1, 2026 and claims for them now deny regardless of what they were prescribed for. Wegovy stopped being eligible for weight loss on the same date. The state will still consider Zepbound for obstructive sleep apnea, and since April 1, 2026 Wegovy needs no prior authorization at all when it is prescribed for MASH.

California Department of Health Care Services, Medi-Cal Rx, effective April 2026 · source

Zepbound goes through sleep apnea. The criteria ask whether you are 18 or over, then whether you have "a diagnosis of moderate to severe obstructive sleep apnea (OSA)," then whether you have "an apnea-hypopnea index (AHI) of at least 15 events per hour on polysomnography (PSG) or home sleep apnea test (HSAT)," and then about a diagnosis of obesity. An initial approval runs 180 days. To renew it you have to show results: "Has the client lost or maintained a loss of at least 5% from their baseline weight?"

Texas Prior Authorization Program Clinical Criteria, Zepbound (Tirzepatide), effective May 2026 · source