Skip to content

Carrier

Kaiser Permanente Mid-Atlantic States

Kaiser Foundation Health Plan of the Mid-Atlantic States · Drug benefit: Kaiser Permanente's own pharmacy (no outside PBM named) · 3 documents cited · Read September 2026

Wegovy by prior authorization with BMI tiers; below BMI 35 an older drug comes first. Zepbound needs a semaglutide trial; Foundayo needs needle fear.

American GLP, Publisher · Who writes this site

Kaiser Permanente's Mid-Atlantic region (Maryland, Virginia and Washington, D.C.) publishes one prior authorization criteria book for its commercial, exchange and federal employee formularies, plus a request form for each GLP-1 family. Whether your own plan covers weight-loss drugs is a question for your plan documents. These papers set the rules once it does.

Wegovy injection is the preferred semaglutide. How much you must try first depends on your starting BMI: below 35, you need a failed trial of an older weight-loss pill; at 35 and above, a documented lifestyle program is enough.

Zepbound needs a semaglutide trial first. Foundayo, the pill, is reserved for people with a documented fear of needles who have already tried oral semaglutide.

What does each BMI band need?

At a BMI of 27 to under 30, you need a weight-related condition, 90 days of documented lifestyle changes, and a failed three-month trial of one older drug such as phentermine, phentermine with topiramate, or naltrexone with bupropion. At 30 to under 35, the condition drops away but the drug trial stays. At 35 to under 40, documented lifestyle changes are enough. At 40 and above, you need to be enrolled in or following a lifestyle program.

What comes before Zepbound and Foundayo?

Zepbound needs a three-month trial of semaglutide at the highest dose you can tolerate, unless you couldn't take it or it didn't get you to 5% weight loss. Foundayo needs a documented fear of needles and a three-month trial of oral semaglutide.

How do you keep the approval?

Approvals start at six months. Renewals for weight management run three to six months at a time, and you need documented weight loss of at least 5% from your baseline plus continued lifestyle changes.

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.

The criteria book is titled "Commercial/Exchange/FEHB Formulary Prior Authorization Criteria" and is "Effective 08/04/2026".

Kaiser Permanente Mid-Atlantic States Region, Commercial/Exchange/FEHB Formulary Prior Authorization Criteria, effective August 2026 · source

The semaglutide form "is used by Kaiser Permanente and/or participating providers for coverage of Semaglutide Products for Commercial, Exchange, and FEHB (Federal) plans." It lists "WEGOVY INJ (ALL OTHER TREATMENT INDICATIONS)" as preferred and Wegovy tablets as non-preferred.

Kaiser Permanente Health Plan of Mid-Atlantic States, Semaglutide Products Prior Authorization (PA) form, effective August 2026 · source

For a baseline BMI of 27 to under 30 or 30 to under 35: "Patient has documented intolerance, contraindication, or failure to lose and maintain >/= 5% body weight after a 3-month trial of one of the following oral medications indicated for weight management", listing phentermine or diethylpropion, phentermine and topiramate, or naltrexone and bupropion.

Kaiser Permanente Health Plan of Mid-Atlantic States, Semaglutide Products Prior Authorization (PA) form, effective August 2026 · source

For a baseline BMI of 35 to under 40, the requirement is "Actively adhering to prescriber-documented lifestyle interventions* (90 days of lifestyle changes documented with nutrition and physical activity components)"; at 40 and above, "Currently enrolled in and/or following a lifestyle intervention program".

Kaiser Permanente Health Plan of Mid-Atlantic States, Semaglutide Products Prior Authorization (PA) form, effective August 2026 · source

Weight-management renewal: "Is there documented weight loss within the previous 3 months of at least 5% from baseline weight". Authorization lengths: "Continuation – 12 months (MASH); 3-6 months (weight management)".

Kaiser Permanente Health Plan of Mid-Atlantic States, Semaglutide Products Prior Authorization (PA) form, effective August 2026 · source

Tirzepatide for weight management asks: "Does the patient have documented intolerance, contraindication, or failure to lose and maintain ≥5% body weight ... after a 3-month trial (at maximum tolerated dose) of semaglutide?" The patient must be "at least 18 years of age", and the form lists "Length of Authorizations: Initial- 6 months".

Kaiser Permanente Health Plan of Mid-Atlantic States, Tirzepatide Products Prior Authorization (PA) form, effective August 2026 · source

Foundayo requires a "documented history of trypanophobia (fear of needles)" and "failure to lose and maintain >/= 5% body weight after a 3-month trial (at the maximum-tolerated dose) of oral semaglutide".

Kaiser Permanente Mid-Atlantic States Region, Commercial/Exchange/FEHB Formulary Prior Authorization Criteria, effective August 2026 · source

What these documents cannot tell you

Everything above is what Kaiser Permanente Mid-Atlantic States 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.

  • These criteria don't say whether your group or plan covers weight-loss drugs at all. Your Evidence of Coverage does.
  • They're the Mid-Atlantic region's rules for commercial, exchange and federal employee plans. Maryland HealthChoice and Virginia Medicaid members follow separate criteria.
  • The forms show the questions a reviewer asks. They don't show how an individual request with borderline records is decided.
  • The list of weight-related conditions and the full Zepbound sleep apnea criteria are longer than shown here.
  • None of this is legal or medical advice. Your plan documents and your notice govern your case.

Where this comes from

  1. Kaiser Permanente Mid-Atlantic States Region, Commercial/Exchange/FEHB Formulary Prior Authorization Criteria, effective August 2026 — Open the document
  2. Kaiser Permanente Health Plan of Mid-Atlantic States, Semaglutide Products Prior Authorization (PA) form, effective August 2026 — Open the document
  3. Kaiser Permanente Health Plan of Mid-Atlantic States, Tirzepatide Products Prior Authorization (PA) form, effective August 2026 — Open the document

Where to go next

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 Kaiser Permanente Mid-Atlantic States publishes. It is not affiliated with Kaiser Foundation Health Plan of the Mid-Atlantic States, and your own plan documents and your own notice govern your case. Policies carry effective dates and change — read the sources before you act.