By plan type

Which plan do you have?

3 plan types · 12 documents cited

The kind of plan you have decides almost everything: which law applies, who can make an exception, and how long you have to appeal. Find yours first, then read its page end to end.

AGAmerican GLP, Publisher · Who writes this site

• Medicare Part DThe law still excludes weight-loss drugs. A separate CMS demonstration pays for some GLP-1s at a $50 monthly copay.
• MedicaidYour state decides. 10 of 50 cover these drugs for weight loss; 33 cover them only for other diagnoses.
• Employer and commercial plansLarge employers cover these drugs far more often than small ones. Your plan document settles it, not the drug.

Know the company? Read what it publishes

If your card names a national carrier, its own coverage policies are public. They settle less about your plan than they seem to, and each page says exactly how much.

• Cigna HealthcarePublishes three different BMI thresholds for the same drugs, and says in writing they are not clinically based.
• UnitedHealthcareSays in its own program document that weight-loss coverage is optional, and sells it to employers who choose to buy it.
• AetnaSays outright that on plans which exclude weight-loss drugs, its clinical criteria do not apply and the claim is denied on the exclusion.
• AnthemIts answer moves several times a year in both directions, and it publishes the news one state at a time.
• BCBS Federal Employee ProgramThe one carrier here whose document actually describes you — and it says the anti-obesity benefit exists.
• HumanaIts Medicare drug plans don't cover GLP-1s for weight loss alone; the $50 Bridge runs beside them through CMS, not Humana.
• Kaiser Permanente NorthwestCovers Wegovy only for members whose plan includes weight-loss drugs, after two older drugs; Zepbound and Foundayo need a semaglutide trial first.
• Kaiser Permanente CaliforniaBoth California HMO formularies list Wegovy on tier 2, and neither lists Zepbound, Foundayo or the Saxenda brand.
• Kaiser Permanente WashingtonMost of its plans exclude weight-loss drugs; members with a weight-loss rider get separate criteria for Wegovy, Zepbound and Foundayo.
• Kaiser Permanente ColoradoWegovy and Zepbound are non-formulary; weight-loss approval needs a plan with that benefit, four older drugs first, and 5% loss to renew.
• Kaiser Permanente GeorgiaIts five-tier formulary puts Wegovy, Zepbound, Foundayo and Saxenda on the specialty tier, each needing prior authorization.
• Kaiser Permanente HawaiiIts Marketplace formulary lists none of Wegovy, Zepbound, Foundayo or Saxenda; the Added Choice plan lists Wegovy and Zepbound with prior authorization.
• Highmark Blue Cross Blue ShieldStandard and Enhanced policy versions are documented from 2025; a public Foundayo request form is now available, but current full criteria remain unverified.
• RegenceCovers Wegovy, Zepbound, Foundayo and Saxenda only where your contract covers weight loss, then asks for 5% loss to renew.
• Blue Cross Blue Shield of MassachusettsEnded GLP-1 coverage for obesity from January 2026 renewals, as an exclusion that can't be appealed, unless a large employer buys it back.
• Premera Blue CrossCovers weight-loss GLP-1s only when the employer elects the benefit, then approves Wegovy for 7 months and renews at 5% weight loss.
• Blue Cross and Blue Shield of TexasCovers Wegovy and the Zepbound auto-injector only for groups that elect GLP-1 coverage, and excludes the Zepbound KwikPen.
• Kaiser Permanente Mid-Atlantic StatesWegovy by prior authorization with BMI tiers; below BMI 35 an older drug comes first. Zepbound needs a semaglutide trial; Foundayo needs needle fear.
• Florida BlueExcludes FDA-approved weight-loss drugs unless a plan buys the coverage separately; its new Wegovy HD, KwikPen and Foundayo rules apply only to those groups.
• Horizon Blue Cross Blue Shield of New JerseyIts Classic drug list names anti-obesity drugs like Wegovy and Zepbound as an excluded class, while listing them on tier 3 for plans that include the benefit.
• Independence Blue CrossCovers weight-loss drugs only where the benefit doesn't exclude them, then requires 5% weight loss to renew Wegovy, Zepbound and Foundayo.
• CareFirst BlueCross BlueShieldLists Wegovy and Foundayo with prior authorization subject to your plan's benefits, and adds Zepbound to two formularies from October 1, 2026.
• Blue Cross Blue Shield of MichiganDoesn't cover GLP-1s for weight loss for fully insured large groups and some self-funded groups; where a group covers them, renewal needs 5% weight loss.
• Blue Cross and Blue Shield of North CarolinaRequires anti-obesity drug coverage on your plan, 6 months of lifestyle change first, and 5% weight loss to renew Wegovy, Zepbound or Foundayo.
• Blue Cross and Blue Shield of IllinoisCovers Wegovy and the Zepbound auto-injector only for groups that elect GLP-1 coverage, excludes the Zepbound KwikPen, and was still reviewing Foundayo.
• Ambetter Health (Centene)Treats Wegovy and Zepbound for weight management as a benefit exclusion, but still reviews Wegovy for heart risk and Zepbound for sleep apnea.
• Molina HealthcareExcludes Wegovy and Zepbound for obesity; most Marketplace plans exclude them for every use, while Illinois Medicaid keeps heart and sleep apnea paths.
• Express ScriptsLists Wegovy, the Zepbound pen and Foundayo for 2026 and 2027, and excludes Saxenda and the Zepbound KwikPen and vials.
• CVS CaremarkOctober 2026 template formularies list Zepbound again; your employer still decides whether your plan covers weight-loss drugs.
• Optum RxIts 2027 lists add Foundayo, drop Saxenda to excluded, and still exclude the Zepbound KwikPen and vials.

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Questions your plan type raises

• Are your appeal rights set by your state or by Washington?Mostly by whether your employer buys insurance or pays claims itself. Insured coverage in a qualifying state uses that state's external review; a self-funded plan usually does not. A handful of states run no process at all.
• What does “not medically necessary” actually mean?It means your file missed a specific written criterion, not that your doctor was wrong. The plan has to explain the clinical judgment it applied to you, or send that explanation free on request. Get the criterion first.
• Does prior authorization mean your plan covers it?Neither yes nor no, and the difference decides what you do. Prior authorization means the drug is on your formulary behind a gate with written criteria you can demand. An exclusion means it is not there at all.
• What is the difference between a formulary exception and a prior authorization?A prior authorization asks your plan to apply its own rule. A Part D formulary exception asks it to set the rule aside, needs your prescriber's supporting statement, and must be granted once the drug is found medically necessary.

Not sure which plan you are on?

Look at the card you show at the pharmacy. A Medicare card, or a card from a Part D or Medicare Advantage plan, means Medicare. A card from your state's Medicaid program, or a managed care plan that names Medicaid, means Medicaid, and then your state decides. A card from an employer, a union or a plan you bought yourself is a commercial plan.