GLP-1 Prior Authorization: Initial vs Renewal — Continuation of Therapy Criteria

Find your reason first: GLP-1 continuation criteria by covered use

Plans don't renew "a GLP-1." They renew one drug, in one form, for one covered use — the reason your prescriber listed on the first request. The proof a renewal needs changes with that reason, so find your row before you gather anything.

Selected rules from named documents, checked September 24, 2026. They are not full approval criteria, and your plan may use a different policy. "None listed" means the named renewal branch states no weight percentage — not that nothing else is required. Document-version limits are explained below the weight-management table.

A few words you'll see a lot. Prior authorization (PA) is the plan’s approval to cover a prescription under its rules. BMI, or body mass index, relates weight to height; it is not the same measurement as weight. Baseline is the starting measurement your policy names. A maintenance dose is the steady dose you stay on after the step-up weeks. A1C (hemoglobin A1C) is a blood test that shows your average blood sugar over the past few months. MASH (metabolic dysfunction-associated steatohepatitis) is a serious form of fatty liver disease. Obstructive sleep apnea (OSA) means your airway keeps closing during sleep, so your breathing stops or gets shallow. AHI counts breathing interruptions per hour. PAP means positive airway pressure; CPAP and BiPAP are types of that treatment. ALT is a liver blood test, ELF is a blood-based fibrosis score, and elastography measures liver stiffness. Your clinician decides which tests are needed.

Found your row? The renewal worksheet turns it into a short to-do list for your prescriber's office.

For a teen, pregnancy or pregnancy plans, type 1 diabetes, an eating-disorder history, or a medication-safety concern, start with the treating clinician. A coverage rule is not a medical clearance.

Initial request or renewal: which one are you making?

An initial request asks your plan to start paying. A renewal asks it to keep paying under its continuation rules. Already taking the medicine doesn't, by itself, put you in the renewal lane — your plan decides which request it's reviewing.

Think of prior authorization as a permission slip from your insurer. It has an expiration date. A renewal asks for a new slip, and the rules for the second slip aren't the same as the first.

For a first request, the office may need the covered diagnosis, starting measurements, earlier treatment trials, and lifestyle-program records. The exact history varies: Aetna’s BMI-35 variant names a 6-month comprehensive program, while the Cigna Wegovy policy names at least a 3-month behavioral and dietary trial. Don’t borrow another plan’s checklist.

Same request, different names. If your paperwork says any of these, you're in the right place:

Renewal isn't automatic. TRICARE's current Wegovy and Zepbound form, for example, requires a renewal every year. Ask your prescriber's office who tracks your end date and who files the renewal. Don't wait for a reminder.

A prescription isn't an authorization. Your prescriber writes the prescription. Your plan's prior authorization is a separate coverage decision with its own end date. A refill on file doesn't prove the approval behind it is still active.

Here's the honest limit: no page, including this one, can tell you if you'll be approved. Your plan decides, using what your prescriber sends. What we can do is show you how to match the records to the rule your plan gives you.

You don't need a new provider to use anything here. But if you also need a different way to get care, the right GLP-1 provider isn't the same for everyone — it depends on your state, your insurance and formulary, FDA-approved or compounded, injection or oral, and your budget. The RX Index's Find My GLP-1 Path tool is free, takes about 2 minutes, and needs no signup. A few quick questions help match GLP-1 paths and providers to your goals, budget, insurance, and situation. It won't renew an authorization or confirm your benefits.

Weight-management renewal rules, plan by plan

For adult weight management, the policies we checked agree on the idea — show a response from your starting weight — but not on the details. Some want 5% lost or kept off after three months at a steady dose. Others count time on treatment, add a program, or use a different number for a different drug.

Four things jump out of that table.

1. "Kept off" counts where the policy says so. Caremark, Aetna and FEP Blue accept keeping your first 5% off. Under those rules, you don't have to lose a brand-new 5% every year.
2. There are two different clocks. Caremark and Aetna count 3 months at a steady maintenance dose. Cigna's renewal branch starts after 8 months on the drug. Those aren't the same thing. Ask which clock your policy uses before you assume you're ready.
3. The pen and the pill can have different clocks. In Aetna’s named variant, the Wegovy pen gets 8 months first. The Wegovy pill gets 6. Caremark’s pill example is also 6 months, but its pen’s initial term needs a version check.
4. Same insurer, different rulebook. Aetna's 6450-C is its BMI-35 variant, not every Aetna plan. UnitedHealthcare's program applies only where the employer or plan chose to cover weight-loss drugs.

Two fine-print notes. These are selected requirements, not a full approval checklist. The periods are authorization lengths if approved—not decision times or guaranteed supplies. Other diagnosis, starting-BMI, lifestyle, safety and preferred-drug rules can still apply. Aetna's 6450-C says it doesn't cover Zepbound vials or KwikPens under this policy; it points to the LillyDirect manufacturer program.

A document-version limit: We received two versions of Caremark’s linked Wegovy document with different initial pen periods: 8 months in version 5 and 7 in version 3. We have not chosen one for your plan. We also received different versions of UnitedHealthcare’s general weight-policy document; the table keeps only product rules that agreed in both and does not assign a current Foundayo or Wegovy HD rule from that document. Ask for the version your plan will use. Its separate Wegovy heart-risk policy is the one to check for that covered use.

Approval lengths for other covered uses

The covered use can change the approval period as well as the evidence. These named examples do not replace the end date on your own approval letter.

Is the 5% renewal rule an FDA rule?

No. Zepbound's current label (revised August 2026) sets no weight-loss cutoff for staying on it. It tells prescribers to consider treatment response and tolerability when choosing the maintenance dose.

Saxenda has a specific label rule. Its U.S. prescribing information tells clinicians to evaluate weight 16 weeks after starting and discontinue it if an adult hasn't lost at least 4%. Several plans use that 4% threshold; FEP Blue’s named adult continuation policy uses 5%. Your clinician handles treatment decisions—not the percentage table.

So the 5% bar for Wegovy, Zepbound and Foundayo comes from the plans' own policies. The label guides the clinician’s treatment decision. The policy answers "will we pay for it?"

Diabetes renewals: Ozempic, Mounjaro, Rybelsus and Trulicity

Diabetes renewals aren't weight-loss renewals. The diabetes policies we read check for a type 2 diabetes diagnosis on record, time on a steady dose, and often a recent A1C. None of them used a weight-loss percentage.

If you take Ozempic or Mounjaro for type 2 diabetes and someone says you need to "lose 5%," ask which policy they're reading. It's probably the wrong one.

A controlled A1C isn't a strike against you. Say your A1C was 8.1% when you started Mounjaro, and it's 6.4% now. Those sample records show both the earlier result and a drop after treatment. Aetna’s policy lists diagnostic history and response criteria; ask your prescriber which combination your assigned policy requires. A lower current result does not erase the earlier record.

Mounjaro and Zepbound both contain tirzepatide, made by Eli Lilly, but they are separate products with different approved uses (Mounjaro label; Zepbound label). Plans review them under different policies, so ask what request the new prescription needs rather than assuming the old approval transfers.

On Medicare? Diabetes GLP-1s go through your Part D plan's rules, not the Medicare GLP-1 Bridge. See what GLP-1s Medicare covers for diabetes.

Which starting weight counts — and do you have to keep losing?

Use the baseline your policy names — not whichever number looks best. Some policies measure from your weight before any GLP-1; others from when you started this drug. Where a policy says "or kept off," holding an earlier 5% loss counts, so you don't have to lose a fresh 5% every year.

That's good news if you've switched drugs. Under Cigna's rules, starting a second GLP-1 doesn't erase your first starting weight.

Do one thing this week: get the dated starting record into your current chart. If your first GLP-1 came from another office or a program that closed, request that record now. Can't get it? Tell the office right away. Don't estimate a starting weight. An unknown baseline isn't a number to guess.

A lower BMI isn't a failed renewal

Don't treat your first-approval BMI as a new hurdle at every renewal. Several policies measure your response from a historical starting point. A lower BMI today is often the proof that treatment worked — it doesn't answer every coverage question, but it isn't a strike against you under those rules.

Here's the math, with sample numbers. Say your plan accepts a recorded starting weight of 200 pounds, and you weigh 190 today.

(200 − 190) ÷ 200 × 100 = 5.00%

At 190.1 pounds, it's (200 − 190.1) ÷ 200 × 100 = 4.95%. That's under a 5% bar, so don't round up. And the math never proves approval by itself — the plan checks its other rules too. These are sample numbers, not a weight goal.

Want the math done for you? The renewal weight calculator in our documents guide does the calculation. It does not decide whether your plan accepts the starting record.

How recent does your current weight need to be?

Check your plan. A current measurement can have a specific date window. The Maryland Physicians Care Wegovy form asks for a BMI measured within the last 90 days for its heart-risk request, including its continuation path. That form still checks a current BMI threshold; don’t assume every plan uses only your original BMI.

The fix is simple: ask your plan what window it uses, then ask the office to get any required measurement close to the day they submit. A 90-day requirement on one form is not a 90-day rule for every renewal.

What if you didn't reach 5%?

It depends on your policy and your covered use. Some policies accept keeping an earlier loss, some covered uses don't use a weight test at all, and a program may have a specific transition provision. Missing a coverage number is never a reason to change your dose or your eating on your own.

We won't give you a target weight, a diet, a calorie number, or a dose trick. If your weight has stalled, that's a conversation for your prescriber — here's what a GLP-1 plateau can mean.

What changes after a gap, a new drug, or a new plan?

A change in treatment or coverage can change which request the plan reviews. Give the office the real dates and your old records instead of assuming the old approval carries over. Then ask your plan whether any rule protects existing patients.

A gap in treatment

Forms ask about your treatment history in different ways. Here they are side by side.

These are insurance-record questions, not restart instructions. Tell your prescriber the real dates — including any stretch you went without because of cost or supply — and let them decide the clinical plan.

A different drug or form

Switching from a pen to a pill, Wegovy to Zepbound, or Zepbound to Mounjaro usually means a separate request under that drug's policy. The same active ingredient doesn't carry an approval over. Under the Medicare Bridge, switching to a different covered drug needs a new prior authorization.

Sometimes the issue is the preferred product or form. Aetna’s BMI-35 variant, for example, excludes Zepbound vials and KwikPens even though it has a Zepbound continuation branch. Ask whether the exact prescription is covered before assuming its drug name is enough.

A new plan, a new plan year, or new rules

A new insurer or plan year can bring new criteria. Keep your old approval anyway, and ask the new plan whether any transition or existing-patient rule applies to you.

An approval can end early if the benefit ends. In a March 25, 2026 Michigan external review, Optum Rx had approved a member's Zepbound through November 10, 2026. The self-funded governmental employer plan ended that coverage at the end of 2025, and the state upheld the denial. Check any approval that crosses a plan year during open enrollment, not after.

Some plans protect existing patients. Virginia's state-employee plan said on August 12, 2026 that members with an active approval who stay continuously compliant can renew under the old BMI rules — 30, or 27 with a related condition. New requests from July 1, 2026 need a BMI of 35. Ask how "active" and "continuously" apply to your own history.

A formulary change can open a door. CVS Caremark says Zepbound returns to its standard commercial formularies as an added preferred option on October 1, 2026 — only for employers and plans that choose it. It's added next to Wegovy, not in place of it. Moving to Zepbound is still its own request under Caremark's Zepbound policy. More in does CVS Caremark cover Zepbound.

Illinois has two protections for plans under its Prior Authorization Reform Act. Section 65 says approval of a maintenance drug for a chronic condition lasts the lesser of 12 months or the length of treatment. Section 70 gives qualifying approvals a 90-day transition when you change plans. These protections do not automatically add an excluded drug to a plan; any applicable medical-exception process is a separate question. Living in Illinois alone doesn't mean your plan is covered by the Act.

The 2025 industry pledge is voluntary. HHS announced insurers' pledge to honor existing authorizations during insurance changes in June 2025. It's a promise, not a coverage decision for you.

You can't predict which way your plan goes. You can ask. Send this to the member-services contact on your card and keep the reply:

"I have an active prior authorization for [drug and form] that ends on [date]. Please confirm in writing: (1) Will my renewal use the criteria I was approved under, or current criteria? (2) What is the policy number and effective date for my renewal? (3) Does my approval carry into the next plan year? (4) Does any transition or existing-patient protection apply to me?"

The answer to question 2 tells your office which rulebook to use — even if it isn't one on this page.

When should your office start the renewal?

Start from your own approval end date, not a number from someone else's plan. Our suggestion is to start gathering records about 60 days before it ends, and to ask the plan how early it accepts renewals. That's a planning cushion, not a plan rule.

Three clocks decide your timing:

An approval length isn't a decision time. The deadline and the event that starts the clock depend on the program:

A dose change also is not a universal reset rule. Ask whether your policy requires a new period at a stable maintenance dose after that change; don’t choose or hold a dose to satisfy paperwork.

One more timing trap: an expired approval isn't the same as a "refill too soon" rejection or a pharmacy stock problem. Ask the pharmacy for the exact rejection before starting new paperwork. Our guide to pharmacy rejection codes explains the common ones.

Why renewals stall: five patterns from policies and public records

A renewal can stall over the record or benefit even when the office has a valid prescription. The sources below show five things to check: the measurement date, the accepted baseline, the exact product, the benefit itself, and a recent A1C. Each points to something you can ask for ahead of time.

These are named policy requirements and one historical appeal—not estimates of how often renewals fail or promises about your outcome.

Medicare, Medicaid and TRICARE

Use the rules of the program that actually pays. A commercial plan's example — or a provider's coverage checker — isn't a substitute for that program's process.

Medicare GLP-1 Bridge vs. regular Part D

The Medicare GLP-1 Bridge has its own refill rules and sits apart from regular Part D. If you're already approved, later fills don't need another prior authorization through December 31, 2027, unless you switch to a different covered GLP-1 (CMS prescriber guide).

Three Bridge details catch people:

• Switching drugs needs a new prior authorization, even mid-year.
• Only 28- or 30-day fills are covered. Don't assume a 90-day prescription works through the Bridge.
• The Bridge has no appeal process. Your prescriber can resubmit with corrected or added information instead.

The reason for treatment matters. CMS directs qualifying type 2 diabetes, sleep-apnea and MASH uses, and prescriptions to lower heart-event risk, through regular Part D rather than the Bridge. A history of heart disease alone does not settle this: the prescribed use matters. Those Part D renewals follow your plan's rules. Full details are in our Medicare GLP-1 Bridge refill rules guide.

Medicaid and TRICARE

Your state, your plan and your covered use all matter. Ask for the policy assigned to your prescription instead of borrowing another state's rules.

One concrete example: Indiana Medicaid's Zepbound sleep apnea criteria ask for 84 days of treatment in the past 112, a 5% weight response, and either improved sleep-study results or the required PAP-use documentation, among other rules. Your sleep clinician and office decide which records fit — don't book a new test on your own. For state-by-state coverage, see our GLP-1 Medicaid coverage tracker.

TRICARE members should use the named form above and the gap questions in it. For Medicare, Medicaid and TRICARE renewals, start with your treating office and the program — not a commercial telehealth service.

If your renewal is denied

Read the written reason before you pick a fix. Missing information, a failed criterion, and an excluded benefit are three different problems with three different fixes. Follow the deadline on your own notice.

For employer plans under ERISA, you generally have at least 180 days to file an internal appeal. For a non-urgent pre-service appeal, the plan generally has 30 days with one internal appeal level, or 15 days at each of two levels. Eligible final denials can go to an independent external review. Medicare, Medicaid and other programs have their own rules — and the Medicare Bridge has no appeal at all.

The Department of Labor’s guide says the denial notice should give the specific reason, the plan provision relied on, any needed information, and how to seek review. Ask for the full written notice when a pharmacy message or brief portal alert is all you have.

A denial isn't proof you did something wrong. In one 2022 New York external appeal, a reviewer overturned a Wegovy continuation denial after seeing a 174-pound starting weight and a 141-pound current weight. That's one historical case, not a promise for yours.

One more distinction: coverage cut off before your approval ended is a different situation from a refused renewal after it expired. Tell the office which one happened.

Know the exact reason, and your program has an appeal route? Build the letter around that reason. Open the GLP-1 appeal letter template →

If you might run out — or need a new prescriber

Tell your prescriber now when your supply runs out, before any decision arrives. Paperwork help, a cash-pay bridge, and a new prescriber are three different kinds of help. Figure out which one you're missing before you pay for anything.

If you have a prescriber: check the manufacturer programs first

LillyDirect sells Zepbound and Foundayo through its pharmacy services, and NovoCare Pharmacy lists Wegovy self-pay options. You still need a valid prescription, and each program has its own rules. If your own prescriber will write the prescription and manage your dose, look here before paying for another care membership. We earn nothing from these two links. We're telling you anyway.

Don’t assume a self-pay purchase will be reimbursed later or count toward your deductible. Check the exact program terms first. For example, Ro’s LillyDirect self-pay terms prohibit seeking insurance reimbursement or counting that purchase toward deductible or out-of-pocket requirements.

When you compare cash prices, compare the same drug, form, dose, and supply length — not a starting-dose promotion against your maintenance-dose bill. For Zepbound dose-by-dose prices, see the cheapest Zepbound without insurance.

Who this section isn't for:

• On Medicare: check the Bridge and Part D rules before paying cash.
• Your plan excludes the drug: the exclusion guide comes first.
• On Medicaid: Ro says Medicaid members aren't eligible for its program. Work with your plan and treating office.
• Renewing for a teen: the adult provider offer below is not the right fit. This belongs with the teen's prescriber and plan — use the teen-specific row above with that care team.

If you need a prescriber and insurance help: Ro

Ro is a telehealth program with affiliated prescribers for FDA-approved brand-name GLP-1s and an insurance team. Here's the candid part first: Ro can't make your plan say yes, and its public pages don't say whether its insurance team takes over renewals for prescriptions written somewhere else. If that's your situation, ask Ro before you pay. What Ro does offer is a prescriber, paperwork help for the drugs it supports through insurance, and cash-pay options if insurance doesn't work out.

Ro’s insurance page says its concierge supports eligible commercial coverage, including Federal Employees Health Benefits (FEHB) plans. Medicare, Medigap and TRICARE members do not get that concierge support and may qualify only for limited cash-pay options. Medicaid members are not eligible for the program.

Ro's listed cash prices at selected doses, checked September 24, 2026. These are price examples—not recommended doses or a list of maintenance doses:

Here’s the membership-plus-medication math, not just the sticker. Say your prescription is Zepbound KwikPen 10 mg and your renewal falls through. With the listed offer, the introductory membership plus one 28-day fill is $39 + $449 = $488. On the monthly membership, one $149 membership charge plus one $449 fill is $598.

The annual membership’s $74 monthly equivalent plus one fill comes to $523, but that is not a monthly bill: the membership costs $888 upfront, and medication is charged separately. A 28-day supply is also not a calendar month, so refill and membership charges do not stay aligned. These examples exclude any additional fees or services; they are not an annual total.

The refill offer has a condition. Lilly’s Zepbound offer gives the listed higher-dose KwikPen price for the first purchase and requires later purchases within 45 days of the previous delivery to keep it. Without that offer, Lilly lists $699 per 28-day supply for the 10 mg, 12.5 mg and 15 mg strengths. The Foundayo offer also requires purchases within 45 days to keep $299 per 30-day supply at 14.5 mg and 17.2 mg; its listed regular self-pay price is $349. That is a pricing deadline, not an instruction to change treatment.

Check the commitment before choosing the annual price. Ro’s terms say paid membership fees are non-refundable and require cancellation at least 48 hours before the next renewal to avoid another membership charge. The terms include up to 24 medical consults per year; extra consults cost $15 each, and additional lab tests can cost extra. Confirm the plan, charge dates and any extra costs at checkout. Prices and offers change, so check Ro's page before you decide.

Need new care, have commercial insurance, and want to check whether a supported option may be covered before paying cash? Ro's free coverage check looks at Wegovy, Zepbound autoinjector and Ozempic pens. It checks coverage; it doesn't prescribe, file an authorization, or confirm that you meet the plan’s clinical criteria.

Check your GLP-1 coverage with Ro

If you need a new prescriber who can handle insurance paperwork — or want to compare FDA-approved cash-pay care — you can get started with Ro for $39, then as low as $74/month with the annual plan paid upfront. Medication is billed separately.

See Ro's current pricing

Want the full picture first? See what Ro's prior-authorization help covers — and doesn't.

Other ways to find a prescriber who helps with paperwork

Other telehealth programs, such as Sesame, offer prescribers who can help with prior-authorization paperwork. Costs and what's included vary, so ask whether this renewal and any follow-up are part of what you pay for. See our Sesame Care review and our comparison of providers that help with prior authorization.

A compounded GLP-1 isn't a way around a renewal. Compounded drugs are not FDA-approved, and the FDA doesn't review them for safety, effectiveness or quality before they're sold. A brand-name authorization is not authorization for a compounded prescription, and we don't recommend switching to one to get past a denial.

What we actually verified

We read the relevant criteria in the plan policies, forms, program guides, labels and provider pages linked below, and matched each published renewal rule to the record it asks for. We didn't check anyone's benefits, submit a prior authorization, or test an approval.

What we actually verified — September 2026

• Checked September 24, 2026: the published policy comparisons, current Kentucky diabetes criteria, Maryland Physicians Care forms, CMS instructions, label distinctions, and the historical Michigan DIFS and New York DFS decisions. The dates on those documents remain separate from this check date.
• Provider-stated, not tested: Ro's prices, insurance help, government-plan limits and membership terms come from its public pages. Lilly's pages supply the refill-offer conditions. We didn't enroll, complete checkout, or submit a request.
• Document limits: Caremark’s Wegovy pen initial period and UnitedHealthcare’s newer-product details could not be reconciled across the versions returned. The table leaves those disputed details unassigned rather than choosing a version for your plan. Aetna’s diabetes page also needs the office to confirm the exact combination of its diagnostic and response criteria.
• What we couldn't confirm: your assigned policy and benefits; whether Ro takes over an outside prescriber’s renewal; how each employer applies Caremark's October 1 change; or your final checkout charges. Those are not promises made by this page.

The RX Index is the independent GLP-1 decision resource that scores telehealth providers and treatment paths on clinical legitimacy, care quality, transparency, access, and cost, so readers can choose the path that fits their situation.

See how we evaluate providers and treatment paths. A licensed clinician — not this page — decides whether a medication is right for you.

GLP-1 renewal questions

Will my plan stop covering it because my BMI is lower now?

Not automatically. Several continuation policies measure your response from a historical starting point instead of treating today's BMI as a new test. Ask which starting and current records your policy requires, and keep both.

What if I didn't lose 5% by renewal time?

Check your policy and your covered use first. Some policies accept keeping an earlier loss, and heart-risk and sleep apnea renewals at some plans list no weight-loss percentage. If you're under a written threshold, get the exact reason and talk with your prescriber — don't change your dose or eating to hit a coverage number.

Do I need a new prior authorization for every refill?

No. An approval usually covers refills until its end date. Then a renewal is needed. On the Medicare GLP-1 Bridge, approved later fills don't need another prior authorization through December 31, 2027, unless you switch covered drugs.

Do I have to lose another 5% every year?

Not where the policy accepts keeping your first 5% off — Caremark, Aetna and FEP Blue say so. Keep your starting record and current weight so the office can show you've held the loss. Other renewal rules still apply.

Is it harder to renew than to get approved the first time?

There is no single harder-or-easier rule. First approval asks whether you meet the starting criteria; renewal asks for the response and treatment records in the continuation branch. The useful question is which exact record your next request needs.

What does "continuation of therapy" mean on a GLP-1 prior authorization?

It is a request to keep covering ongoing treatment under the plan’s continuation rules. Taking the drug already does not, by itself, prove that a new plan will review it as continuation. Aetna and CVS Caremark use the phrase; UnitedHealthcare says "reauthorization." The plan checks its continuation rules, which differ from the rules to start.

Is the 5% renewal rule an FDA rule?

No. Zepbound's current label sets no weight-loss cutoff for staying on it; the 5% bar comes from plan policies. Saxenda’s label has a separate rule: clinicians evaluate the adult’s response at week 16 and discontinue it if the loss is under 4%. Discuss treatment with your prescriber rather than stopping or changing it on your own.

Do I need to lose weight to renew Wegovy for heart disease?

Check the heart-risk policy, not just the general weight-management policy. Aetna’s and Caremark’s named heart-risk renewal branches list no weight-loss percentage, and UnitedHealthcare’s separate program 1445 does not list one in its heart-risk renewal branch either. Other conditions still apply, so send the records your assigned branch requests.

What do plans need to renew Ozempic or Mounjaro for diabetes? What if my A1C is controlled now?

The named diabetes policies use diagnosis and treatment records, often including a recent A1C—not a weight-loss percentage. A controlled A1C doesn’t erase your diagnosis history. Aetna lists diagnostic and response criteria; ask your prescriber which combination your assigned policy requires, rather than assuming a lower A1C alone guarantees renewal.

How recent does my weight need to be for a renewal?

Ask your plan for its date window. Maryland Physicians Care’s Wegovy heart-risk form, for example, asks for a BMI from the last 90 days; that is not a universal rule. Have the office obtain the required current measurement within your plan’s window.

How long is a Wegovy, Zepbound or Foundayo approval good for?

Your approval notice has your real end date. In the named Wegovy, Zepbound and Foundayo weight-management examples with confirmed initial periods, first approvals run 5 to 12 months and renewals are usually 12 months. Pills can differ from pens: Aetna and Caremark list 6 months initially for the Wegovy pill; Aetna’s named pen variant lists 8. The table flags the source-version limits instead of guessing your approval period.

Does switching from a shot to a pill — or from Zepbound to Mounjaro — need a new request?

Usually, yes. Each drug and form is reviewed under its own policy, and the same active ingredient doesn't carry an approval over. Your prescriber makes the medication decision; the plan decides how the new prescription is reviewed.

I don't know my starting weight or my policy number. What now?

Ask your plan for the policy assigned to your prescription, and ask your office for the dated record that policy names. An old visit note may be the missing piece. Don't substitute an estimate or your highest-ever weight just to get a percentage.

I changed insurance. Does my old approval count?

Keep it, and ask. A new plan may require its own review, but some plans and states have transition rules — Illinois, for example, gives qualifying approvals a 90-day transition. Ask whether your exact drug is covered and which policy will apply.

Can a provider guarantee my renewal?

No. A provider can assess your treatment and may help with the paperwork, but no one can promise your plan's decision. Before paying for new care, ask whether this specific renewal and its follow-up are included.

Does my approval cover a compounded version?

Don't assume it does. The policies on this page cover FDA-approved brand-name drugs, and compounded drugs are not FDA-approved. Ask your plan about the exact product, and talk with your clinician about treatment.

Related guides: How to get insurance to cover a GLP-1 · Documents needed for GLP-1 prior authorization · Plan exclusion vs. prior authorization · CVS Caremark Zepbound prior authorization · OptumRx Zepbound prior authorization · Express Scripts Zepbound prior authorization · Wegovy heart disease prior authorization · Does insurance cover Zepbound for sleep apnea? · GLP-1 maintenance dose · GLP-1 BMI eligibility chart · Medicare GLP-1 Bridge refill rules

Sources

Source checks: September 24, 2026. Document dates below identify the source’s version, publication or effective date—not a new date for an old decision. Source-version limits are stated next to the affected comparisons.

Plan policies and forms

1. Aetna — Weight Loss (BMI 35), 6450-C, version 8 — page dated April 10, 2026
2. Aetna — Antidiabetic GLP-1/GIP-GLP-1, 2439-C, version 4 — page dated March 18, 2026; exact criteria combination must match the assigned form
3. CVS Caremark — Wegovy 4774-C — document-version discrepancy; pen initial period not assigned here
4. CVS Caremark — Zepbound 6192-C — P08-2025
5. CVS Caremark — Global Prior Authorization Form
6. UnitedHealthcare — Weight Loss/Appetite Suppression program 1114 — different versions returned; only shared product rules shown
7. UnitedHealthcare — Wegovy cardiovascular risk reduction and MASH, program 1445 — separate from its weight-management policy
8. UnitedHealthcare — Zepbound sleep-apnea program 1475 — shared response and duration requirements shown; confirm the assigned version
9. Cigna — Wegovy injection IP0814 — effective September 1, 2026
10. Cigna — Zepbound IP0816 — effective September 1, 2026
11. Cigna — Foundayo CNF1007 — reviewed June 17, 2026
12. FEP Blue — Saxenda/Wegovy 5.99.030 — effective July 1, 2026
13. FEP Blue — Zepbound 5.99.031 — effective July 1, 2026
14. Express Scripts/TRICARE — Wegovy and Zepbound form — dated March 12, 2026
15. Maryland Physicians Care — diabetes GLP-1 products form — version June 2026
16. Maryland Physicians Care — Wegovy form — version February 2026

Medicaid and state documents

1. Optum Rx — Indiana Medicaid GLP-1 criteria — October 1, 2025 document
2. TennCare/Optum Rx — Weight Management Agents form — transition provision, not an open-ended extension
3. CareOregon — Diabetic GLP-1 Agonists guideline — effective July 21, 2026; 12-month/2-month distinction shown
4. Kentucky Medicaid — Prior Authorization Criteria — September 2026; preferred and nonpreferred GLP-1 renewal sections, printed pages 155–156
5. Kentucky Medicaid — current drug-information document index — identifies the current monthly documents
6. MedStar Family Choice Maryland — GLP-1 provider alert — April 29, 2026; change effective June 1, 2026
7. Virginia DHRM — updated GLP-1 prior-authorization criteria — August 12, 2026
8. Illinois Prior Authorization Reform Act — 215 ILCS 200/65 — scope and exceptions matter
9. Illinois Prior Authorization Reform Act — 215 ILCS 200/70 — transition protection for qualifying approvals

Hearing and appeal records (dated history)

1. Michigan DIFS — external review 244942-001-SF — March 25, 2026
2. New York DFS — external appeal 202208-152420 — 2022

Federal programs and rules

1. CMS — Medicare GLP-1 Bridge: Information for Prescribers
2. CMS — Medicare GLP-1 Bridge: Information for Providers
3. CMS — Medicare Part D coverage determinations
4. U.S. Department of Labor — Filing a Claim for Your Health Benefits
5. HealthCare.gov — Internal appeals
6. HHS/CMS — industry prior-authorization pledge announcement — June 23, 2025

Labels, FDA and formulary announcements

1. Zepbound prescribing information — revised August 2026
2. Saxenda U.S. prescribing information — adult response assessment in section 2.3
3. Wegovy U.S. prescribing information — product forms, indications and dose distinctions
4. Foundayo U.S. prescribing information
5. Mounjaro U.S. prescribing information
6. FDA — Compounding and the FDA: Questions and Answers — no compounded-access recommendation is made here
7. CVS Health — Caremark GLP-1 formulary update — May 28, 2026; October 1 change is still upcoming on our check date

Provider and manufacturer pages

1. Ro — program pricing
2. Ro — program and insurance
3. Ro — free GLP-1 insurance coverage checker
4. Ro — Terms of Use — revised April 2, 2026; Body Membership and LillyDirect self-pay terms
5. Lilly — Zepbound self-pay prices and offer terms
6. Lilly — Foundayo self-pay prices and offer terms
7. LillyDirect
8. NovoCare Pharmacy — Wegovy
9. Sesame — Zepbound and prior-authorization help

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