Carrier
Kaiser Permanente Washington
Most of its plans exclude weight-loss drugs; members with a weight-loss rider get separate criteria for Wegovy, Zepbound and Foundayo.
Kaiser Permanente Washington says the thing most insurers bury: most of its plans exclude drugs for weight loss. Its formularies print that in the introduction.
The exception is a weight-loss rider. Kaiser's commercial prior authorization criteria, effective September 1, 2026, end the entries for Saxenda, Foundayo, Wegovy and Zepbound with the same note: specific weight-loss criteria exist for members whose plan has that rider.
Without the rider, Zepbound has one route of its own: severe sleep apnea with obesity, after older drugs and six months of semaglutide.
How do you know if you have the weight-loss rider?
It isn't in the criteria or the formulary. It's in your Benefit Booklet, and Kaiser tells you to check there or call Member Services. Ask them directly whether your plan includes a weight-loss drug rider.
What does the Zepbound sleep apnea route ask for?
Severe sleep apnea on a sleep study (an AHI of 30 or more), a BMI of 30 or more, a record of using CPAP or not tolerating it, a 3-month trial of Qsymia or liraglutide, and at least 6 months on semaglutide without reaching more than 10% weight loss.
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.
"Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, drugs for weight loss, and drugs used for cosmetic purposes."
Kaiser Permanente Washington, 2026 Drug Formulary for Large Employer Groups, effective September 2026 · source
The commercial criteria are "Effective 09/01/2026", and the entries for Saxenda, Foundayo, Wegovy and Zepbound each carry "NOTE: specific weight loss criteria available for members with a weight loss rider plan."
Kaiser Permanente Washington (KPWA), Commercial Pharmacy Benefit Prior Authorization Criteria, effective September 2026 · source
Zepbound for sleep apnea: "Covered for patients with a documented diagnosis of severe obstructive sleep apnea (OSA) defined by baseline as apnea-hypopnea index (AHI) ≥ 30", with a BMI of 30 or more and "Documented use of PAP, or attestation of intolerance to or failure of PAP".
Kaiser Permanente Washington (KPWA), Commercial Pharmacy Benefit Prior Authorization Criteria, effective September 2026 · source
The same entry requires that the "Patient has documented intolerance* or failed to achieve weight loss > 10% on an adequate trial of at least 6 months on semaglutide (Ozempic)", and says it's "Not covered for patients with central or mixed sleep apnea, or planned procedure for sleep apnea or obesity".
Kaiser Permanente Washington (KPWA), Commercial Pharmacy Benefit Prior Authorization Criteria, effective September 2026 · source
The formulary for "individual and family plans or covered through small employer groups" lists Zepbound and the Zepbound KwikPen on tier 3 with prior authorization and a quantity limit.
Kaiser Permanente Washington, 2026 Drug Formulary for individual, family and small employer plans, effective September 2026 · source
"Drug coverage is based on an individual's contracted benefit. Coverage for a specific drug is subject to each member's medical coverage agreement."
Kaiser Permanente Washington, 2026 Drug Formulary for Large Employer Groups · source
What these documents cannot tell you
Everything above is what Kaiser Permanente Washington 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.
- The weight-loss criteria for rider members are mentioned in the criteria document but not printed in it, so we can't quote them.
- Kaiser Permanente Northwest, which covers southwest Washington, is a separate region with its own page here.
- Medicare, federal employee and Apple Health (Medicaid) plans use other lists.
- None of this is legal or medical advice. Your Benefit Booklet and your notice govern your case.
Where this comes from
- Kaiser Permanente Washington, 2026 Drug Formulary for Large Employer Groups, effective September 2026 — Open the document
- Kaiser Permanente Washington (KPWA), Commercial Pharmacy Benefit Prior Authorization Criteria, effective September 2026 — Open the document
- Kaiser Permanente Washington, 2026 Drug Formulary for individual, family and small employer plans, effective September 2026 — Open the document
Where to go next
- Kaiser Permanente Northwest's criteria
- Premera Blue Cross: the employer elects the benefit
- Zepbound for sleep apnea: when coverage changes
- When a weight-loss exclusion doesn't block every use
- 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 Kaiser Permanente Washington publishes. It is not affiliated with Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc., and your own plan documents and your own notice govern your case. Policies carry effective dates and change — read the sources before you act.