Zepbound prior authorization: what insurers require

Caremark's Zepbound criteria (6192-C) require that "The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy." You then need either "a baseline body mass index (BMI) greater than or equal to 30 kg/m2" or "a baseline BMI greater than or equal to 27 kg/m2" with "at least ONE weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)." Each BMI line is tagged "[ACTION REQUIRED: Documentation is required for approval.]" To continue, "The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss." For weight management: "Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months". For sleep apnea: "Obstructive Sleep Apnea (OSA): Initial therapy DOA: 6 months; Continuation of therapy DOA: 12 months". The document covers all forms "except the vials, which are covered under the LillyDirect manufacturer program."

CVS Caremark, Initial Prior Authorization with Quantity Limit, Zepbound, Weight Loss Management (6192-C) · source

Cigna's Zepbound policy IP0816, effective September 1, 2026 (printed as 09/01/2026), says "Prior Authorization is required for benefit coverage of Zepbound." For weight loss: "Approve for 8 months if the patient meets ALL of the following", including "Patient is ≥ 18 years of age", "Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months", and "At baseline, patient had a BMI ≥ 30 kg/m2" or a BMI of at least 27 with one listed comorbidity. Baseline means "baseline prior to any glucagon-like peptide-1 (GLP-1) agonist". Renewal: "Patient is Currently Receiving Zepbound. Approve for 1 year" where "Patient has lost ≥ 5% of baseline body weight". For sleep apnea, renewal after "completed ≥ 1 year of therapy with Zepbound" needs "Patient has lost ≥ 10% of baseline body weight".

Cigna Healthcare, Drug Coverage Policy IP0816, Zepbound, effective September 2026 · source

UnitedHealthcare's weight-loss program (2026 P 1114-22, effective 9/1/2026) requires the drug be "Used as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)" and a "Body Mass Index (BMI) ≥ 30 kg/m2", or a BMI of at least 27 where the "Patient has a weight-related comorbidity (e.g., dyslipidemia, hypertension, type 2 diabetes, sleep apnea)". It states: "Foundayo, Xenical or Zepbound: Authorization will be issued for 6 months." Reauthorization needs "Weight loss of ≥ 5% of baseline body weight for all other appetite suppressants" and "Continuation of lifestyle modification", then "Authorization for Contrave, Foundayo, Qsymia, Saxenda, Wegovy injection or tablet, Wegovy HD, Xenical or Zepbound will be issued for 12 months."

UnitedHealthcare, Clinical Pharmacy Programs, Prior Authorization/Notification, Plans with Weight Loss/Appetite Suppression Medication Coverage (2026 P 1114-22), effective September 2026 · source

UnitedHealthcare describes its weight-loss coverage as something an employer buys rather than something its members have. The program's own background section opens: "This is an optional program that is put in place for clients or businesses that have elected to cover weight loss products with Prior Authorization/Notification."

UnitedHealthcare, Clinical Pharmacy Programs, "Prior Authorization/Notification – Plans with Weight Loss/Appetite Suppression Medication Coverage" (2026 P 1114-22), effective September 2026 · source

Aetna's policy "Weight Loss (BMI 35) GIP-GLP-1, GLP-1 Agonists PA with Limit 6450-C P08-2025 v8" requires that "The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy." and that "The patient has a baseline body mass index (BMI) greater than or equal to 35". To continue Wegovy, Zepbound or Foundayo: "The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose." and "The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss." For tirzepatide weight management: "Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months". The policy excludes "Zepbound vials and Zepbound Kwikpens, which are covered under the LillyDirect manufacturer program."

Aetna, Pharmacy Clinical Policy Bulletin, Weight Loss (BMI 35) GIP-GLP-1, GLP-1 Agonists PA with Limit 6450-C, effective April 2026 · source

Kaiser Permanente Northwest's Zepbound criteria ("Effective: 11/05/26") state "Non-Formulary tirzepatide (Zepbound) requires a clinical review." For weight management it "will be covered on the prescription drug benefit for 12 months when the following criteria are met", including a BMI of at least 30, or 27 with a listed condition, and that the "current weight and BMI has been documented within the last 30 days approximately". The patient must be "actively making lifestyle modification (diet and/or exercise) or have an active behavioral health referral to assist with lifestyle modification", and "has then failed a minimum 6-month trial of semaglutide (Ozempic/Wegovy)". "Continued use criteria (every 12 months)" require: "Achieved and maintained 5% or greater weight loss after starting tirzepatide (Zepbound)".

Kaiser Permanente Northwest Region, Criteria for tirzepatide (Zepbound) Coverage, effective November 2026 · source

Express Scripts does not post its weight-loss criteria on its prior authorization page. It says: "Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request." The same page says to use its general request form "if you would like to request a coverage determination (such as a step therapy exception) or if you would like to make an appeal for us to reconsider a coverage decision."

Evernorth / Express Scripts, Prior Authorization Resources · source

The 2026 exclusions list names "ZEPBOUND KWIKPENS, ZEPBOUND VIALS" under Weight Loss, with "liraglutide, FOUNDAYO, WEGOVY HD, WEGOVY PENS, WEGOVY TABLETS, ZEPBOUND PENS" as the preferred alternatives, and adds: "Not all the medications listed are covered by all prescription plans; check your benefit materials."

Express Scripts, 2026 National Preferred Formulary Exclusions (EXCL-NPF-26), effective July 2026 · source

Optum Rx's January 1, 2027 Premium prior authorization list opens: "Prior authorization (PA) requires your doctor to tell us why you are taking a medication to determine if it will be covered under your pharmacy benefit." If you need the drug right away, it says to "check with your pharmacy to request a short-term supply of 5 days or less. Keep in mind, you will be responsible for the full cost at that time."

Optum Rx, Prior Authorization, Premium Formulary Utilization Management, effective January 2027 · source

Optum's January 2027 Premium prior-authorization list, under Weight Loss, sets quantity limits of "1 tablet per day" for Foundayo and the Wegovy tablet, "4 syringes per 28 days" for Wegovy, Wegovy HD and Zepbound, and "5 syringes per 30 days" for liraglutide.

Optum Rx, Prior Authorization – Premium Formulary Utilization Management, effective January 2027 · source

Lilly's Zepbound Prior Authorization Resource Guide (CMAT-21629) for prescribers says "Please provide complete and correct information in the PA request to avoid denied claims" and lists: "Documentation of BMI is required of either obesity (BMI ≥30 kg/m2) or overweight (BMI ≥27 to <30 kg/m2)"; a record of a "weight management program or a reduced-calorie diet/exercise regimen for at least 3-6 months"; "Initial authorization duration: ~6-8 months, therefore, reauthorization will be required"; and "Documentation that patient has lost or maintained a loss of at least 5% from their baseline weight". It adds "Actual coverage requirements will vary." and says to "Call 1-800-LillyRx to speak with a live agent for benefits verification, PA support, and more."

Eli Lilly, Zepbound Prior Authorization Resource Guide (CMAT-21629), effective April 2026 · source

Lilly's Zepbound coverage page for prescribers says of the vial and KwikPen sold through LillyDirect: "No prior authorization is needed. Conditions apply, including that patients must certify that they have been prescribed the Zepbound vial or KwikPen for an approved use consistent with FDA-approved product labeling." The same page offers "Letter of medical necessity" and prior authorization guides for prescribers.

Eli Lilly, Zepbound for HCPs: Coverage and savings, effective August 2026 · source

"CVS Caremark will add Zepbound back to our commercial formularies as an additional preferred option October 1, 2026 ... Additionally, effective June 1, 2026, CVS Caremark will remove the new-to-market block on Foundayo™(orforglipron), a new oral GLP-1 therapy, where approved for coverage by plans." The release adds: "Plan sponsors that adopt CVS Caremark template formularies retain discretion to customize coverage for their members."

CVS Health newsroom, release on GLP-1 weight-management coverage options, effective May 2026 · source