Carrier
Highmark Blue Cross Blue Shield
Standard and Enhanced policy versions are documented from 2025; a public Foundayo request form is now available, but current full criteria remain unverified.
The Standard and Enhanced policy versions quoted here took effect in 2025. They establish what those editions said, not that their full criteria remain current for every Highmark plan. Ask which current policy and benefit apply to your group before your prescriber files.
The older Standard edition uses a BMI of 30, or 27 with a related condition, and three months of lifestyle participation. The older Enhanced edition is stricter: a BMI of 40 with additional conditions, six months of diet and activity changes, and a preference for Zepbound. The dates and exact requirements of those editions appear below.
Everything in both policies starts with "When a benefit": if your plan doesn't include weight-loss drugs, neither set of criteria applies.
Which policy is yours?
The older policy describes a self-funded (ASO) employer plan choosing Enhanced or Standard. Highmark's 2024 bulletin distinguished fully insured and ACA plans from self-funded ones. Neither document establishes your current group's benefit; ask Member Services for the applicable policy title, version and effective date.
What changes on renewal?
The 2025 Standard version asks for 5% weight loss from baseline to continue Wegovy or Zepbound, or 4% for Saxenda. The 2025 Enhanced version asks for maintained loss of 7.5%. Confirm the current continuation criteria before relying on those historical thresholds.
What does the public Foundayo request form establish?
Highmark's provider forms page now links a Foundayo-specific authorization form. It asks for documented diet and physical-activity participation, weight-related conditions, baseline measurements and, for people already treated, current measurements and treatment history. It also asks about intolerance or contraindication to Zepbound.
These are questions on a submission form, not a complete approval algorithm. The form does not identify a Standard or Enhanced policy version or establish a coverage entitlement. It expressly says authorization does not guarantee payment. Ask the prescriber to use the current form and confirm the policy behind the request.
Every claim above, with the document behind it
These are the policies we opened and the month we opened them. Each one carries its own policy number and effective date on its face, and those are printed here as the document shows them.
Read September 2026
Enhanced policy (J-1388, version 013, effective 08/26/2025): "When a benefit, initiation of Saxenda, Wegovy, or Zepbound may be approved when all of the following criteria are met", including "The member has a baseline BMI ≥ 40 kg/m2".
Highmark, Pharmacy Policy Bulletin J-1388 Anti-Obesity (Enhanced), Commercial and Healthcare Reform, effective August 2025 · source
The Enhanced policy also requires that "The member maintained healthy dietary changes for at least 6 months prior to initiation of the requested therapy", and for Wegovy or Saxenda, intolerance or a contraindication "to plan-preferred Zepbound."
Highmark, Pharmacy Policy Bulletin J-1388 Anti-Obesity (Enhanced), Commercial and Healthcare Reform, effective August 2025 · source
Enhanced maintenance: "The member has experienced and maintained ≥ 7.5% weight loss from baseline."
Highmark, Pharmacy Policy Bulletin J-1388 Anti-Obesity (Enhanced), Commercial and Healthcare Reform, effective August 2025 · source
Standard policy (J-1389, version 010, effective 10/02/2025): "The member has a baseline BMI ≥ 30 kg/m2" or "The member has a baseline BMI ≥ 27 kg/m2 and has a weight related comorbidity", and "The member actively participated for at least 3 months prior to initiation of the requested therapy in a lifestyle modification program that encourages reduced calorie diet and increased physical activity".
Highmark, Pharmacy Policy Bulletin J-1389 Anti-Obesity (Standard), Commercial, effective October 2025 · source
Standard continuation for Wegovy and for Zepbound: "The member has experienced ≥ 5% weight loss from baseline." For Saxenda the figure is 4%.
Highmark, Pharmacy Policy Bulletin J-1389 Anti-Obesity (Standard), Commercial, effective October 2025 · source
Highmark's August 30, 2024 bulletin applied the revised criteria to fully insured and ACA plans: "Prior authorization criteria for weight loss medications for Highmark's commercial self-insured members is not impacted." It adds: "Coverage is governed by the terms of the member's health benefits plan."
Highmark, Special Bulletin: Revised Prescription Medication Policy for Weight Loss Medications, effective September 2024 · source
Read October 2026
Highmark's public Foundayo request form asks for lifestyle documentation, baseline and current measurements, treatment history and Zepbound intolerance or contraindication. It does not identify a full policy version and says authorization does not guarantee payment.
Highmark, Foundayo Medication Prior Authorization Form · source
The Highmark provider forms directory, last updated September 23, 2026, links a Foundayo-specific prior authorization form.
Highmark, Pharmacy Prior Authorization Forms · source
What these documents cannot tell you
Everything above is what Highmark Blue Cross Blue Shield publishes. None of it establishes what your own plan does, and the gap between those two things is wider than a carrier policy makes it look.
- Highmark's January 2026 update reports revisions adding Foundayo. The October 15 reread found a public Foundayo request form, but did not verify the newer full Standard and Enhanced policy versions. The older thresholds above must not be assumed to govern a current Foundayo request.
- Which policy your plan uses, Standard or Enhanced, isn't something these documents can tell you.
- Medicare Advantage plans aren't covered by these policies.
- None of this is legal or medical advice. Your plan documents and your notice govern your case.
Where this comes from
Read September 2026 unless marked.
- Highmark, Pharmacy Policy Bulletin J-1388 Anti-Obesity (Enhanced), Commercial and Healthcare Reform, effective August 2025 — Open the document
- Highmark, Pharmacy Policy Bulletin J-1389 Anti-Obesity (Standard), Commercial, effective October 2025 — Open the document
- Highmark, Special Bulletin: Revised Prescription Medication Policy for Weight Loss Medications, effective September 2024 — Open the document
- Highmark, Foundayo Medication Prior Authorization Form — Open the document (read October 2026)
- Highmark, Pharmacy Prior Authorization Forms — Open the document (read October 2026)
Where to go next
- Independence Blue Cross: the benefit comes first
- How employer and commercial plans treat GLP-1s
- Zepbound prior authorization criteria
- How to appeal a commercial or employer plan denial
- Every carrier we have read
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 Highmark Blue Cross Blue Shield publishes. It is not affiliated with Highmark Inc. (Pennsylvania, West Virginia, Delaware and New York), and your own plan documents and your own notice govern your case. Policies carry effective dates and change — read the sources before you act.