GLP-1 prior authorization requirements by insurer do not reduce to one rule per company — and the reason is not that insurers are vague. It is that one insurer can publish several rules at once.
In our July 31, 2026 review of 20 adult Wegovy and Zepbound chronic weight-management pathways in 10 current public policy documents from Cigna, UnitedHealthcare, CVS Caremark, Aetna, and the Blue Cross Blue Shield Federal Employee Program, we found four obesity-alone BMI floors in simultaneous force: 30, 32, 35, and 40. Every pathway required a BMI gate, a lifestyle or weight-management condition, at least 5% weight loss or maintenance for continuation, and a 12-month renewal period. Fourteen of 20 specified a fixed three- or six-month pre-treatment lifestyle period; one of 20 explicitly required trials of two oral weight-management drugs; initial approvals ranged from five to eight months.
“BMI 30, or 27 with a comorbidity” is common in this sample. It is not the rule. Eleven of 20 pathways used a BMI-30 floor, while nine did not.
Cigna alone publishes three current threshold families — IP0206, BEO005, and BEO006 — all effective June 1, 2026, with obesity-alone floors of 30, 32, and 35 for the Wegovy and Zepbound branches reviewed here. UnitedHealthcare’s single current weight-loss document contains a BMI-30 general pathway and a BMI-40 North Dakota fully insured Essential Health Benefits pathway. Both of Cigna’s benefit-exclusion override policies say their adult weight-loss BMI thresholds are not based on clinical data and are provided in the product offering to allow a subset of patients to obtain the medications.
Here is the whole benchmark in one screen.
| Measure | Result |
|---|---|
| Adult Wegovy/Zepbound chronic weight-management pathways coded | 20 |
| Current public policy documents represented | 10 |
| Organizations or programs represented | 5 |
| Distinct obesity-alone BMI floors | 4 — 30, 32, 35 and 40 |
| Pathways with a BMI gate | 20 of 20 |
| Pathways with a lifestyle or weight-management condition | 20 of 20 |
| Pathways requiring ≥5% loss or maintenance for continuation | 20 of 20 |
| Pathways with a fixed pre-treatment lifestyle period | 14 of 20 |
| Fixed periods observed | 3 or 6 months |
| Pathways explicitly requiring trials of two oral weight-management drugs | 1 of 20 |
| Initial approval range | 5–8 months |
| Renewal period | 12 months in 20 of 20 |
Source: The RX Index GLP-1 Prior Authorization Public-Policy Matrix, version 2026-07-31. Sample definition: 20 adult Wegovy/Zepbound chronic weight-management pathways in 10 public documents. This is not 20 independent insurers, not an enrollment-weighted national estimate, and not a count of every public template an organization publishes.
Dataset: CSV, version 2026-07-31The convergence in that table is real. So is the divergence underneath it. Both matter.
What are the GLP-1 prior authorization requirements by insurer in 2026?
There is no reliable one-rule-per-insurer answer. The requirement governing a prescription is set by the combination of plan, pharmacy benefit manager, formulary, drug, formulation, indication, policy scope, and effective date. Public policies are accurate reference points for the plans they cover, but a company’s name alone does not tell you which policy controls.
That is not a hedge. It is what the documents themselves say.
UnitedHealthcare Program 2026 P 1114-21, effective July 1, 2026, calls itself an optional program for clients or businesses that elected to cover weight-loss products with prior authorization. It also contains state-specific provisions. Cigna’s current policies say the customer’s benefit plan document can differ from the standard policy and controls in a conflict. Aetna 6450-C calls itself a partial, general description of plan benefits rather than a contract. CVS Caremark’s public criteria likewise operate inside a member’s plan and formulary rather than as one universal Caremark benefit.
The 20 coded pathways break down like this:
| Obesity-alone BMI floor | Pathways | Where it appears | Lower-BMI route |
|---|---|---|---|
| 30 | 11 of 20 | Cigna IP0206 and CNF684; UHC general; CVS Caremark Wegovy and Zepbound; FEP Wegovy and Zepbound | BMI ≥27 plus one qualifying comorbidity or established cardiovascular disease, depending on policy |
| 32 | 2 of 20 | Cigna BEO005: Wegovy and Zepbound | BMI ≥27 plus two qualifying comorbidities |
| 35 | 5 of 20 | Cigna BEO006: Wegovy and Zepbound; Aetna 6450-C: two Wegovy formulation rows and Zepbound | Cigna BEO006: BMI ≥27 plus two comorbidities; Aetna 6450-C: no lower-BMI adult route stated |
| 40 | 2 of 20 | UHC North Dakota fully insured EHB section: Wegovy and Zepbound | No lower-BMI adult route stated in that section |
Source: The RX Index coding of Cigna IP0206, BEO005, BEO006 and CNF684; UnitedHealthcare Program 2026 P 1114-21; CVS Caremark 4774-C and 6192-C; Aetna 6450-C; and FEP 5.99.030 and 5.99.031. Version 2026-07-31.
The UHC BMI-40 number is real, but it is not the general UnitedHealthcare rule. It appears in the North Dakota fully insured EHB section for small-group and individual plans. The general commercial pathway in the same document uses BMI ≥30, or BMI ≥27 with a weight-related comorbidity. Both statements are true of a UnitedHealthcare document. Neither should be stated as the company’s one nationwide requirement.
Terms, defined once. Prior authorization is a plan requirement that approval be obtained before the plan will pay under the applicable benefit. Formulary is the plan’s covered-drug list and coverage position. Nonformulary means the drug is not on that list; an exception process may exist. Step therapy requires trying specified treatments first. Pharmacy benefit manager (PBM) is the company administering the drug benefit, which can differ from the insurer on the card. Plan sponsor is the employer or organization that chose the benefit design.
Why does the same insurer publish more than one BMI threshold?
Because the policy being applied can be a different benefit product, formulary program, or exclusion override. Cigna currently publishes BMI-30, BMI-32, and BMI-35 policy families for adult weight-management GLP-1 coverage. UnitedHealthcare places BMI-30 and BMI-40 pathways in different sections of one document.
Cigna’s current public identifiers matter. Older indexed copies can still appear under IP0621 and IP0739. The documents verified for this dataset are BEO005 and BEO006, both effective June 1, 2026.
We read the three current Cigna threshold policies end to end. Here is what changes and what does not.
| Current policy | Policy type | Obesity-alone floor | Overweight route | Prior lifestyle | Initial approval | Extra condition |
|---|---|---|---|---|---|---|
| IP0206 | Drug coverage policy | BMI ≥30 | BMI ≥27 + 1 comorbidity | 3 months | 8 months | None beyond the coded policy criteria |
| BEO005 | Benefit-exclusion override | BMI ≥32 | BMI ≥27 + 2 comorbidities | 3 months | 8 months | Four weigh-ins and four app engagements per month with the designated lifestyle vendor |
| BEO006 | Benefit-exclusion override | BMI ≥35 | BMI ≥27 + 2 comorbidities | 3 months | 8 months | No BEO005-style monthly engagement quota stated |
Source: Cigna Drug Coverage Policies IP0206, BEO005, and BEO006, each effective June 1, 2026. Retrieved and coded by The RX Index on July 31, 2026.
Both BEO005 and BEO006 describe the adult entry thresholds as product-offering parameters rather than clinically derived cutoffs. BEO005 adds something else that no other pathway in this sample states: four weigh-ins and four app engagements every month through a designated lifestyle vendor.
What this looks like for one patient
Same person. Same insurer. Same day. Three answers.
Adult, age 44, BMI 31, hypertension as one qualifying comorbidity, no prior GLP-1 use, and a documented four-month diet-and-behavior program, requesting Zepbound:
| Policy applied | Obesity-alone floor | Overweight route | Result for the stated profile |
|---|---|---|---|
| Cigna IP0206 | 31 meets ≥30 | Not needed | Passes the coded BMI-and-lifestyle gate |
| Cigna BEO005 | 31 does not meet ≥32 | One comorbidity; policy requires two | Fails the coded BMI gate |
| Cigna BEO006 | 31 does not meet ≥35 | One comorbidity; policy requires two | Fails the coded BMI gate |
Source: The RX Index worked example applying the published BMI, comorbidity-count, and pre-treatment lifestyle conditions in Cigna IP0206, BEO005, and BEO006. It does not assume formulary placement, preferred-product compliance, benefit eligibility, or final approval.
Nothing in the stated clinical profile changes across the three rows. The policy changes.
That does not prove why any employer selected a particular option. It does prove that “Cigna’s BMI requirement” is not one number.
What do the 2026 GLP-1 prior authorization data show — and what do they not show?
The sample shows complete convergence on four coded elements: an adult BMI gate, a lifestyle or weight-management condition, a 5% continuation threshold, and a 12-month renewal period. It also shows real divergence in entry thresholds, fixed lifestyle periods, medication steps, stable-dose requirements, and initial approval lengths. These are unweighted pathway counts, not estimates of how many insured people face each rule.
What the benchmark supports:
- Every one of the 20 coded pathways contained an adult BMI gate.
- Every pathway required lifestyle modification, program participation, or a documented pre-treatment program.
- Every pathway required at least 5% loss from baseline body weight or maintenance of an initial 5% loss for continuation.
- Every coded renewal period was 12 months.
- Fourteen pathways specified a fixed period before treatment: three months in the eight Cigna rows and six months in the six CVS Caremark and Aetna rows.
- Six pathways required at least three months at a stable maintenance dose before continuation.
- One pathway — FEP Zepbound — explicitly required inadequate response, intolerance, or contraindication to two oral weight-management medications.
- Initial approvals ranged from five to eight months.
What the benchmark does not support:
- The share of Americans subject to any one rule. The rows are not enrollment-weighted.
- Approval rates, denial rates, appeal results, or decision times. We coded written criteria, not adjudications.
- A conclusion that the five organizations or programs are statistically independent. CVS Caremark administers pharmacy benefits for Aetna products, and several Cigna rows are parallel policy families from one issuer.
- A conclusion that a drug is on a member’s formulary. Clinical criteria and formulary placement are separate.
- A conclusion that every public Cigna template was counted. We deliberately excluded near-duplicate templates that repeat an already included threshold structure.
- A determination about a particular member’s coverage.
Where a table says “not stated,” it means the requirement did not appear in the coded public branch. It does not mean the requirement cannot exist in a plan document, formulary rule, state mandate, preferred-product program, or member-specific benefit.
How do Wegovy and Zepbound requirements compare across insurers and plans?
The concepts repeat; the numbers do not. Aetna’s sampled policy uses BMI 35 with six months of prior program participation and no lower-BMI adult route. UnitedHealthcare’s general pathway uses BMI 30 or BMI 27 with a comorbidity and no fixed prior period. CVS Caremark’s public standard criteria use six months. The FEP Zepbound pathway is the only row that explicitly requires two oral weight-management drugs first.
| Policy pathway | Scope | Drug/formulation | BMI gate | Lifestyle before initiation | Medication step | Initial | Continuation | Renewal |
|---|---|---|---|---|---|---|---|---|
| Cigna IP0206 | Plan-specific Cigna policy | Wegovy injection/HD/tablet | ≥30 or ≥27 + 1 | 3 months | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| Cigna IP0206 | Plan-specific Cigna policy | Zepbound | ≥30 or ≥27 + 1 | 3 months | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| Cigna BEO005 | Benefit-exclusion override | Wegovy injection/HD/tablet | ≥32 or ≥27 + 2 | 3 months + vendor quota | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| Cigna BEO005 | Benefit-exclusion override | Zepbound | ≥32 or ≥27 + 2 | 3 months + vendor quota | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| Cigna BEO006 | Benefit-exclusion override | Wegovy injection/HD/tablet | ≥35 or ≥27 + 2 | 3 months | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| Cigna BEO006 | Benefit-exclusion override | Zepbound | ≥35 or ≥27 + 2 | 3 months | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| Cigna CNF684 | National Formulary policy | Wegovy injection/HD/tablet | ≥30 or ≥27 + 1 | 3 months | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| Cigna CNF684 | National Formulary policy | Zepbound | ≥30 or ≥27 + 1 | 3 months | Not stated | 8 mo | ≥5%; continued lifestyle | 12 mo |
| UHC 2026 P 1114-21 | General commercial; elected benefit | Wegovy injection/tablet | ≥30 or ≥27 + 1 | Concurrent; no fixed period | Not stated | 5 mo | ≥5%; continued lifestyle | 12 mo |
| UHC 2026 P 1114-21 | General commercial; elected benefit | Zepbound | ≥30 or ≥27 + 1 | Concurrent; no fixed period | Not stated | 6 mo | ≥5%; continued lifestyle | 12 mo |
| UHC 2026 P 1114-21 | North Dakota fully insured EHB | Wegovy injection/tablet | ≥40 | Concurrent; no fixed period | Not stated | 5 mo | ≥5%; continued lifestyle | 12 mo |
| UHC 2026 P 1114-21 | North Dakota fully insured EHB | Zepbound | ≥40 | Concurrent; no fixed period | Not stated | 6 mo | ≥5%; continued lifestyle | 12 mo |
| CVS Caremark 4774-C | Standard public criteria; plan-specific | Wegovy injection | ≥30 or ≥27 + 1 | 6 months | Not stated | 7 mo | 3 mo stable dose + ≥5% or maintenance | 12 mo |
| CVS Caremark 4774-C | Standard public criteria; plan-specific | Wegovy tablet | ≥30 or ≥27 + 1 | 6 months | Not stated | 6 mo | 3 mo stable dose + ≥5% or maintenance | 12 mo |
| CVS Caremark 6192-C | Standard public criteria; plan-specific | Zepbound | ≥30 or ≥27 + 1 | 6 months | Not stated | 8 mo | 3 mo stable dose + ≥5% or maintenance | 12 mo |
| Aetna 6450-C | Aetna non-Medicare; plan-specific | Wegovy injection/HD | ≥35; no lower route stated | 6 months | Not stated | 8 mo | 3 mo stable dose + ≥5% or maintenance | 12 mo |
| Aetna 6450-C | Aetna non-Medicare; plan-specific | Wegovy tablet | ≥35; no lower route stated | 6 months | Not stated | 6 mo | 3 mo stable dose + ≥5% or maintenance | 12 mo |
| Aetna 6450-C | Aetna non-Medicare; plan-specific | Zepbound | ≥35; no lower route stated | 6 months | Not stated | 8 mo | 3 mo stable dose + ≥5% or maintenance | 12 mo |
| FEP 5.99.030 | Federal Employee Program | Wegovy injection/tablet | ≥30, or ≥27 + established CVD or 1 comorbidity | Program participation; no fixed period | Not stated | 6 mo | ≥5% or maintenance + program | 12 mo |
| FEP 5.99.031 | Federal Employee Program; formulary exclusion | Zepbound | ≥30, or ≥27 + established CVD or 1 comorbidity | Program participation; no fixed period | Two oral drugs + preferred product | 6 mo | ≥5% or maintenance + program | 12 mo |
Source: The linked Cigna, UnitedHealthcare, CVS Caremark, Aetna, and FEP issuer documents. Dataset version 2026-07-31. “Not stated” means absent from the coded public branch, not necessarily absent from a member’s plan.
Three details in that table change the answer in practice.
One drug, two clocks. CVS Caremark 4774-C grants seven months initially for Wegovy injection and six months for Wegovy tablet. Aetna 6450-C grants eight months for Wegovy injection/HD and six for the tablet. A drug name without a formulation is not enough to state the approval period.
“Lifestyle requirement” is not one requirement. UnitedHealthcare requires concurrent lifestyle modification and states no fixed prior period in the coded branch. Cigna requires three months before treatment. CVS Caremark and Aetna require six months of a comprehensive program with continuing follow-up. FEP requires program participation without stating a fixed prior duration.
Medication step therapy is not universal. FEP Zepbound explicitly requires two oral weight-management medications and a preferred-product trial unless an exception applies. No equivalent two-oral-drug step appears in the other 19 coded public branches. That does not rule out separate plan-specific steps.
What is identical across the 20 pathways?
Four elements were present in every coded pathway: an adult BMI gate, a lifestyle or weight-management condition, at least 5% loss or maintenance for continuation, and a 12-month renewal period. Three other requirements were common but not universal: a fixed pre-treatment period, explicit use of pre-treatment BMI, and three months at a stable maintenance dose.
| Measured element | Result | What the count means |
|---|---|---|
| Documented BMI gate | 20 of 20 | Every coded initiation pathway contained an adult BMI requirement |
| Lifestyle or weight-management condition | 20 of 20 | A fixed pre-treatment period, concurrent lifestyle modification, program participation, or a combination |
| ≥5% continuation threshold | 20 of 20 | Loss from baseline or maintenance of an initial 5% loss, depending on wording |
| 12-month renewal period | 20 of 20 | Every coded continuation approval lasted 12 months |
| Fixed pre-treatment lifestyle period | 14 of 20 | Three months in eight Cigna rows; six months in three CVS Caremark and three Aetna rows |
| Three months at a stable maintenance dose | 6 of 20 | All three CVS Caremark rows and all three Aetna rows |
| Pre-treatment BMI reference stated explicitly | 14 of 20 | All eight Cigna rows, all three CVS Caremark rows and all three Aetna rows |
| Two oral weight-management drugs required | 1 of 20 | FEP Zepbound only |
Source: The RX Index GLP-1 Prior Authorization Public-Policy Matrix, version 2026-07-31.
The invariants are useful. The limits are just as useful. “Prepare for BMI documentation, lifestyle documentation, and a renewal weight” is supported by all 20 rows. “Every plan requires six months,” “every plan uses starting BMI,” and “every plan requires step therapy” are not.
How long is a GLP-1 prior authorization approved for?
Initial Wegovy and Zepbound approvals in the benchmark ranged from five to eight months. Two pathways were five months, six were six months, one was seven months, and eleven were eight months. Every renewal period was 12 months.
| Initial approval | Pathways | Count |
|---|---|---|
| 5 months | UHC general Wegovy; UHC North Dakota Wegovy | 2 |
| 6 months | UHC general Zepbound; UHC North Dakota Zepbound; CVS Caremark Wegovy tablet; Aetna Wegovy tablet; FEP Wegovy; FEP Zepbound | 6 |
| 7 months | CVS Caremark Wegovy injection | 1 |
| 8 months | Eight Cigna rows; CVS Caremark Zepbound; Aetna Wegovy injection/HD; Aetna Zepbound | 11 |
Source: The RX Index GLP-1 Prior Authorization Public-Policy Matrix, version 2026-07-31.
The spread is not cosmetic. UHC grants five months initially for Wegovy. Cigna grants eight months in each of the four policy families included here. That is a three-month difference before the first continuation review.
The documents state the durations. They do not provide one shared explanation for why each organization chose its number, so this dataset does not assign one.
What must be shown for a GLP-1 renewal?
All 20 pathways required at least 5% loss from baseline body weight or maintenance of an initial 5% loss, and every coded renewal lasted 12 months. Six pathways added at least three months at a stable maintenance dose: all three CVS Caremark rows and all three Aetna rows.
The word maintenance matters. CVS Caremark, Aetna, and FEP explicitly allow continuation when the patient has maintained an initial 5% loss rather than requiring a fresh 5% reduction during every authorization cycle.
The documents also separate entry thresholds from response thresholds. Cigna IP0206 says sustained loss of at least 5% may produce clinically meaningful health benefits. BEO005 and BEO006 separately say their adult entry BMI thresholds are not based on clinical data. The documents themselves therefore treat “Who enters?” and “Who is responding?” as different questions.
UnitedHealthcare’s wider weight-loss policy shows that the response threshold is drug-specific outside this Wegovy/Zepbound benchmark: it uses 4% for Saxenda, 5% for Wegovy and Zepbound, and 3% for Qsymia. That is why the 5% result should be stated as a Wegovy/Zepbound finding, not as a universal rule for every anti-obesity medication.
Does weight already lost count when BMI is reviewed?
In 14 of 20 pathways, the public policy explicitly ties the initiation BMI to the value before GLP-1 therapy or at the start of any weight-loss drug therapy. The four UnitedHealthcare and two FEP initiation branches do not state the same universal instruction. “Every insurer uses starting BMI” is therefore too broad.
| Policy family | Initiation BMI tied explicitly to pre-treatment baseline? | What the public text says |
|---|---|---|
| Cigna — 8 pathways | Yes | Baseline is defined as before any GLP-1 or GLP-1/GIP agonist |
| CVS Caremark — 3 pathways | Yes | If transitioning from another weight-loss drug, use BMI at the start of any drug therapy |
| Aetna — 3 pathways | Yes | The coded adult branch uses baseline BMI and directs transition cases back to the start of drug therapy |
| UnitedHealthcare — 4 pathways | Not stated in the initiation branch | The public policy states a BMI threshold and later measures renewal loss from baseline body weight, but does not add the same pre-treatment-BMI instruction |
| FEP — 2 pathways | Not stated in the initiation branch | The public criteria state the BMI gate and renewal loss from baseline body weight without an equivalent initiation instruction |
Source: The linked Cigna, CVS Caremark, Aetna, UnitedHealthcare, and FEP policy branches. Dataset version 2026-07-31.
For the 14 explicit pathways, the practical rule is clear: preserve the pre-treatment height, weight, BMI, therapy start date, and any qualifying comorbidity record. A patient whose BMI fell after treatment is not reclassified as though treatment never happened under those documents.
CMS uses the same logic in the separate Medicare GLP-1 Bridge. Its provider guidance gives an example of a beneficiary who began therapy at BMI 37 and is at BMI 34 during a July 2026 request; the provider attests to the BMI at therapy initiation.
For UnitedHealthcare and FEP, the public continuation criteria still measure loss from baseline body weight, but their public initiation language does not contain the same pre-treatment-BMI instruction. The exact governing plan document should supply the answer.
Do Ozempic and Mounjaro follow the same prior authorization rules?
Usually not. Wegovy and Zepbound chronic weight-management branches are built around BMI, lifestyle treatment, and continuation weight loss. Ozempic and Mounjaro diabetes branches are built around type 2 diabetes, clinical records or claims evidence, and product-specific eligibility. Coverage of one establishes nothing about the other.
| Public pathway | Drugs | Primary gate | Approval period | Why it is separate |
|---|---|---|---|---|
| UnitedHealthcare diabetes GLP-1 policy | Ozempic, Mounjaro, Rybelsus, Trulicity, Victoza and others | Type 2 diabetes supported by claims, chart or specified laboratory evidence | 12 months | The policy states these products are not approved for weight loss; member benefits still control |
| Cigna National Formulary diabetes policy | Ozempic, Mounjaro and other diabetes GLP-1 products | Type 2 diabetes plus the applicable product age criterion | 1 year | Weight-loss treatment is not covered through this diabetes policy branch |
Source: The linked UnitedHealthcare and Cigna diabetes GLP-1 policies. Retrieved July 31, 2026.
The separation is explicit inside CVS Caremark 4774-C. Its Wegovy cardiovascular-risk pathway requires that the patient not have type 2 diabetes and points to Ozempic as the cardiovascular-risk product for adults with type 2 diabetes and established cardiovascular disease.
This is why “Ozempic was covered but Wegovy was denied” is not automatically a contradiction. It can be two different indications, two different products, two different benefit categories, and two different policies doing exactly what they say.
What other GLP-1 indication pathways can change the answer?
Weight management is not the only published pathway for these drugs. Separate branches exist for Zepbound in moderate-to-severe obstructive sleep apnea, Wegovy in cardiovascular-risk reduction, and Wegovy injection in noncirrhotic MASH with F2–F3 fibrosis. Those branches use different evidence and cannot be folded into the 20-row weight-management count.
| Separate indication | Representative public criterion | What not to infer |
|---|---|---|
| Zepbound for moderate-to-severe obstructive sleep apnea | CVS Caremark 6192-C requires AHI ≥15 and current BMI ≥30. Cigna IP0206 uses baseline BMI ≥30 and, after one year, requires ≥10% loss plus stability in OSA signs or symptoms. | A separate OSA branch does not prove the member’s plan covers it |
| Wegovy for cardiovascular risk reduction | CVS Caremark 4774-C uses BMI ≥27, established cardiovascular disease, no type 2 diabetes and guideline-directed cardiovascular therapy or a clinical reason not to use it. | A weight-management denial does not establish the result under the cardiovascular branch |
| Wegovy injection for MASH with F2–F3 fibrosis | UnitedHealthcare 2026 P 1114-21 states no BMI requirement for its MASH branch. Cigna CNF684 and CVS Caremark 4774-C publish fibrosis- and liver-disease-specific criteria. | Do not mix MASH criteria into the 20-row chronic weight-management benchmark |
Source: The linked CVS Caremark, Cigna, and UnitedHealthcare issuer policies. Retrieved July 31, 2026.
A separate indication branch is evidence that the issuer published separate criteria. It is not evidence that every member has the corresponding benefit. Formulary position, benefit exclusions, product scope, and the governing plan still control.
The distinction can be large. UHC’s current policy says there is no BMI requirement for its Wegovy MASH branch. Cigna’s Zepbound OSA branch, by contrast, uses baseline BMI 30 and an apnea-hypopnea index of at least 15, then requires at least 10% loss after one year plus stability in OSA signs or symptoms. Neither rule belongs in a generic “weight-loss BMI requirement.”
Why can the same insurer cover one GLP-1 and exclude another?
Because clinical criteria and formulary status answer different questions. A policy can describe the clinical conditions used in a review while the formulary lists the drug as nonformulary. Meeting clinical criteria does not put a drug on the formulary, and formulary placement does not remove prior authorization.
The cleanest public example is inside Aetna.
Aetna’s May 2026 Advanced Control Plan formulary lists Wegovy as a preferred brand subject to prior authorization and lists Zepbound as nonformulary. Aetna 6450-C separately publishes adult clinical criteria for Wegovy and Zepbound. Both documents can be current because they answer different questions.
This is an example from one named formulary, not an Aetna-wide statement. The sampled formulary and 6450-C are separate artifacts, and the page does not claim that every member using one is governed by the other.
| Coverage state | What it means |
|---|---|
| Covered with prior authorization | The drug is in the plan’s covered benefit, but approval is required before payment |
| Nonpreferred | The drug is covered at a less favorable formulary position and may carry additional utilization rules |
| Nonformulary | The drug is not on the formulary; a formulary-exception process may be required |
| Benefit exclusion | The plan does not include the drug or indication in the benefit; ordinary clinical PA criteria may never be reached |
Source: The RX Index synthesis of the sampled Aetna formulary and the governing-plan language in the issuer policies reviewed. Version 2026-07-31.
Cigna BEO005 and BEO006 show another layer. They are benefit-exclusion override policies: narrower pathways designed to authorize specified coverage where the base benefit otherwise excludes weight-loss drugs. That is how one issuer can publish different thresholds without one document canceling the others.
Why is there no one nationwide rule per insurer?
Because several names people search are not one national rulebook. Some are associations of independent companies. Some are PBMs administering different formularies for different employers. Some are insurers whose weight-loss policy applies only when the client bought the benefit.
| Name searched | What it is | Can one nationwide rule be stated? | What controls the answer |
|---|---|---|---|
| Aetna | Insurer; pharmacy benefits may be administered by CVS Caremark | No | Exact Aetna product, formulary, benefit, state and policy bulletin |
| Anthem / CarelonRx | Insurer brand and PBM relationship across multiple products | No | The employer’s or plan’s specific CarelonRx drug list |
| Blue Cross Blue Shield | Association of independent, locally operated companies | No | The local Blue plan; FEP is a separate nationwide program |
| Cigna | Insurer and plan administrator | Not safely | The governing plan document and the applicable policy family; current public BMI families include 30, 32 and 35 |
| CVS Caremark | Pharmacy benefit manager, not one health-insurance plan | No | Plan sponsor, benefit design and formulary |
| Humana | Insurer across commercial, Medicare and Medicaid products | No | Product line, state, formulary and benefit year |
| Kaiser Permanente | Integrated health plan with regional formularies | No | Kaiser region and exact plan |
| UnitedHealthcare | Insurer; pharmacy benefits may be administered through Optum Rx | No | Whether weight-loss coverage was elected, state provisions and member-specific benefits |
Source: CarelonRx drug-list architecture, BCBS company structure, Humana drug-list tools, Kaiser formulary lookup, and the Cigna, CVS Caremark, Aetna, and UHC documents cited in this page. Retrieved July 31, 2026.
The insurer name is the first lookup field, not the answer.
What changes under Medicare and Medicaid?
Medicare and Medicaid should not be inserted into the commercial 20-row benchmark. The Medicare GLP-1 Bridge is a separate federal demonstration with a central prior-authorization route. Medicaid obesity coverage is state-specific and optional under federal drug-coverage rules.
Medicare GLP-1 Bridge
The Medicare GLP-1 Bridge runs from July 1, 2026, through December 31, 2027. CMS uses a single central processor for prior authorization, claims adjudication, and pharmacy payment. The copay is $50 per eligible 30-day supply.
The Bridge operates outside the Part D benefit payment flow. CMS states that the Part D deductible does not apply, the $50 does not count toward true out-of-pocket costs, and the Part D low-income subsidy does not reduce it.
| Medicare GLP-1 Bridge route | Clinical criterion at therapy initiation |
|---|---|
| BMI route 1 | BMI ≥35 |
| BMI route 2 | BMI ≥30 plus heart failure with preserved ejection fraction, uncontrolled hypertension despite two antihypertensive medications, or chronic kidney disease stage 3a or above |
| BMI route 3 | BMI ≥27 plus prediabetes, previous myocardial infarction, previous stroke, or symptomatic peripheral artery disease |
| All routes | Age 18 or older, weight-management use and current, ongoing structured nutrition and physical activity |
Source: CMS Medicare GLP-1 Bridge provider guidance, last modified July 13, 2026.
Eligible weight-management products listed by CMS are Foundayo, all Wegovy formulations, and Zepbound KwikPen. The single-dose Zepbound vial and single-dose pen are not included in the Bridge.
CMS assesses the clinical criteria at the time GLP-1 therapy was initiated. Type 2 diabetes, moderate-to-severe obstructive sleep apnea, and noncirrhotic MASH remain Part D-covered indications rather than Bridge indications. CMS separately says that a prescription written to reduce the risk of major adverse cardiovascular events should be routed to the Part D plan, even where the Bridge’s BMI-27 criteria overlap. A beneficiary using a GLP-1 for a Part D-covered indication continues through the Part D plan.
The Medicare Bridge is excluded from the 20-row insurer benchmark because it is a federal demonstration with its own eligibility structure, products, payment route, and indication rules.
Medicaid
Under 42 U.S.C. § 1396r-8(d)(2)(A), state Medicaid programs may exclude or restrict agents when used for weight loss, making obesity coverage a state decision. KFF counted 13 state fee-for-service programs covering GLP-1s for obesity in January 2026, down from 16 in October 2025. The RX Index’s separate GLP-1 Medicaid Coverage by State tracker verified 11 state programs with current adult obesity coverage as of July 10, 2026, after Utah’s pilot ended June 30 and Massachusetts ended coverage July 1.
The state-level source record is maintained in that tracker and is not duplicated into this commercial-policy denominator.
Self-funded employer plans
A self-funded employer can decide whether anti-obesity medications are included at all and can adopt, modify, or decline a PBM’s standard criteria. That is why “CVS Caremark requires X” is often too broad. Caremark can publish a standard policy while different plan sponsors use different formularies and benefits.
Why does this data matter now?
The pool of people who may meet clinical BMI criteria is much larger than the pool whose employer plans cover GLP-1s for weight loss. The resulting gap is where benefit exclusions, formularies, prior authorization, and continuation rules do their work.
| Measure | Value | Original data producer | As of |
|---|---|---|---|
| Nonelderly employer-insured people who medically qualify for a GLP-1 based on BMI | 34% — 36.2 million | Peterson-KFF Health System Tracker | 2025 analysis |
| Firms with 200+ workers covering GLP-1s primarily for weight loss | 19% | KFF Employer Health Benefits Survey | 2025 |
| Firms with 5,000+ workers covering them | 43%, up from 28% in 2024 | KFF Employer Health Benefits Survey | 2025 |
| Firms with 1,000–4,999 workers covering them | 30%, up from 24% | KFF Employer Health Benefits Survey | 2025 |
| Firms with 200–999 workers covering them | 16%, unchanged | KFF Employer Health Benefits Survey | 2025 |
| Covering firms requiring professional consultation or lifestyle-program enrollment | 34% | KFF Employer Health Benefits Survey | 2025 |
| Covering firms with 5,000+ workers reporting a significant prescription-spend impact | 66% | KFF Employer Health Benefits Survey | 2025 |
| State Medicaid programs verified with current adult GLP-1 obesity coverage | 11; KFF counted 13 fee-for-service programs in January 2026 | The RX Index state tracker; KFF | July 10, 2026 |
Source: Peterson-KFF Health System Tracker, KFF 2025 Employer Health Benefits Survey, KFF Medicaid coverage analysis, and The RX Index state tracker. Each figure carries its own as-of date.
The documents also move quickly.
- UnitedHealthcare’s current weight-loss policy records six Pharmacy and Therapeutics approvals from March 2025 through April 2026.
- Aetna’s sampled Advanced Control formulary says it is updated during the first week of each month and that older versions cease to be effective.
- Cigna’s current BMI-32 and BMI-35 documents are BEO005 and BEO006, effective June 1, 2026; older identifiers can remain visible in indexes and saved copies.
An undated statement of “what an insurer requires” can be accurate when written and wrong when read. That is why the source version, effective date, retrieval date, and change history sit next to the data rather than in a hidden note.
How to build your dataset query: the nine-step sequence
Start with the plan, not the carrier logo. The reliable sequence is: identify the exact plan, identify the pharmacy-benefit administrator, confirm that the benefit exists, check the exact drug and formulation on the current formulary, then open the applicable clinical criteria and verify the policy date and indication.
- Read the exact plan name from the card, Summary Plan Description, Evidence of Coverage, or pharmacy-benefit documents.
- Identify the pharmacy benefit administrator. It may differ from the medical insurer.
- Confirm whether weight-management drugs are included in the benefit. If they are excluded, clinical criteria may never be reached.
- Search the current formulary for the exact drug and formulation. Wegovy injection and tablet can have different approval periods.
- Record the coverage position: preferred, nonpreferred, nonformulary, PA, step therapy, quantity limit, or benefit exclusion.
- Open the linked criteria and verify the effective date or version.
- Match the prescription to the right indication branch: weight management, cardiovascular risk, OSA, MASH, or type 2 diabetes.
- Preserve baseline records where the policy uses pre-treatment BMI or baseline body weight.
- Use the governing plan document when it conflicts with a general public policy. Cigna and Aetna say this directly.
This is a map of how the documents fit together. It is not a coverage determination and does not replace the plan’s current records or the prescriber’s clinical judgment.
How was the GLP-1 insurer-policy dataset built?
The dataset was assembled from public issuer documents, normalized into one row structure, and checked a second time against each source. One row represents one named drug’s adult chronic weight-management pathway within one policy document and plan scope; formulations share a row only when every coded adult criterion and approval duration matches. The benchmark separates pathways when a different formulation, plan section, or policy changes a coded field that matters.
What counted as a source
A pathway entered the benchmark only when:
- the document came from the insurer, PBM, program, or regulator itself;
- it was publicly accessible without a member login;
- the adult chronic weight-management pathway for Wegovy or Zepbound could be isolated;
- initiation and continuation rules could be distinguished;
- the policy scope, version, effective date, or current public status could be recorded.
We excluded manufacturer access guides, provider blogs, forum accounts, screenshots without a reproducible public source, pediatric-only pathways, diabetes pathways, cardiovascular-risk pathways, MASH pathways, obstructive-sleep-apnea pathways, Medicaid state policies, and the Medicare GLP-1 Bridge from the 20-row denominator. Those topics are handled separately above.
The unit of analysis
One drug-policy pathway is one named drug’s adult chronic weight-management branch inside one public document and plan scope. Formulations share a row only when every coded adult criterion and approval duration matches.
We combined formulations only when their coded adult initiation criteria, continuation criteria, and approval periods matched. That is why:
- Cigna’s Wegovy injection, HD injection, and tablet can share one row within a policy;
- UnitedHealthcare’s adult Wegovy injection and tablet branches can share one row within a plan scope;
- CVS Caremark’s Wegovy injection and tablet are split because the injection receives seven months initially and the tablet receives six;
- Aetna’s Wegovy injection/HD branch and tablet branch are split for the same reason;
- UHC’s general pathway and North Dakota EHB pathway are separate rows even though they live in one PDF, because their BMI gates differ.
The analytic population is adults age 18 and older. Policies that also contain pediatric or older-adolescent criteria remain outside these adult rows.
How we prevented template volume from becoming the result
Cigna publishes more parallel public templates than the other organizations in this benchmark. Counting every near-identical template would make the denominator partly a measure of how many documents Cigna publishes.
We therefore included:
- one current Cigna document for each distinct threshold family: IP0206 at BMI 30, BEO005 at BMI 32, and BEO006 at BMI 35;
- CNF684 because it is a separate National Formulary PA policy with a separate stated scope.
We disclosed but did not count current sibling templates such as CNF908 and CNF950, which repeat included BMI-32 and BMI-35 structures. This rule was set before recalculating the summary statistics.
Coding rules
- Preserve the policy’s operative meaning rather than turning it into a broader insurer claim.
- Use
not statedwhen a requirement is absent from the coded branch. Never turn that intonot required. - Keep a fixed pre-treatment period separate from concurrent lifestyle modification.
- Keep clinical criteria separate from formulary status.
- Keep the general UHC pathway separate from the North Dakota EHB section.
- Split formulations when approval duration or another coded adult criterion differs.
- Record both the original wording and a normalized value in the dataset.
- Record a source title, URL, policy identifier, effective or revision date, retrieval date, and source section.
- Recalculate every count from the frozen CSV rather than editing headline figures by hand.
Verification sequence
Each source was retrieved from its issuer, coded into the matrix, and checked again against the original document. The 20-row CSV was then frozen as version 2026-07-31, and the summary counts were generated from that file. The visible “Last verified” date changes only after the document links, row values, calculations, and page copy have been checked together.
Limitations
We would rather state these plainly than have a reader discover them.
- This dataset describes public policy documents, not live claims systems. A plan’s adjudication logic or member portal can contain information not visible in the public document.
- The sample is not enrollment-weighted. Twenty pathways in ten documents are not a representative sample of American insurance.
- The rows are not independent observations. Aetna and CVS Caremark are affiliated in pharmacy-benefit administration, and multiple Cigna rows are parallel products from one issuer.
- The benchmark is deliberately deduplicated. Additional Cigna sibling templates repeat included threshold structures and were disclosed but excluded.
- We measured written criteria, not outcomes. Nothing here estimates approvals, denials, appeals, abandonment, time to decision, or patient access.
- “Not stated” is not “not required.” Plan documents, state mandates, preferred-product programs, and separate utilization rules can add conditions.
- A public PBM standard is not necessarily a plan sponsor’s final rule. Self-funded employers can modify the benefit.
- Clinical criteria do not establish formulary coverage. A drug can meet the clinical criteria and remain nonformulary.
- FEP is not a proxy for local Blue plans. It is one distinct federal program.
- The pre-treatment-BMI result is not universal. It is explicit in 14 pathways and not stated in six public initiation branches.
- Policy dates do not all use the same convention. Some documents state an effective date, some a review or version date, and some publish a revision history. The source ledger records the strongest date the issuer supplied.
- The benchmark covers adult chronic weight management for Wegovy and Zepbound only. It excludes pediatric, diabetes, cardiovascular-risk, OSA, MASH, Medicare Bridge, and Medicaid pathways from its counts.
- This is educational information, not medical, legal, or insurance advice. Treatment questions belong with a qualified clinician; member-specific benefit questions belong with the plan.
How to cite this page
This reference identifies the dataset version and verification date so that a figure can be traced to the policy snapshot used.
For a table note:
The linked policy documents remain the property of their issuers. The RX Index’s original contribution is the source selection rule, row-level coding, normalization, comparison, and calculation.
Frequently asked questions
Does every insurer require prior authorization for GLP-1 drugs?
No. Prior authorization depends on the plan, drug, indication and benefit design. Some plans cover a GLP-1 without prior authorization, some require it, some make the drug nonformulary and require an exception, and some exclude weight-management drugs entirely. All 20 pathways in this dataset require prior authorization because the sample was built from public prior-authorization policies; that is not evidence about all plans.
What BMI is required for Wegovy or Zepbound?
It depends on the policy governing the plan. Across the 20 pathways coded on July 31, 2026, obesity-alone BMI floors were 30, 32, 35 and 40. Eleven pathways used 30, two used 32, five used 35 and two used 40. Lower-BMI routes also differed: some used BMI 27 plus one comorbidity, Cigna’s BMI-32 and BMI-35 override policies used BMI 27 plus two, and Aetna 6450-C and UHC’s North Dakota EHB section stated no lower adult route.
Do insurers always require six months of diet and exercise first?
No. Fourteen of 20 pathways specified a fixed pre-treatment period: eight Cigna pathways required three months, while three CVS Caremark and three Aetna pathways required six months. UnitedHealthcare and FEP required lifestyle modification or program participation but stated no fixed pre-treatment duration in the coded branches.
Is step therapy always required before Wegovy or Zepbound?
No. One of 20 pathways — the FEP Zepbound formulary-exclusion pathway — explicitly required inadequate response, intolerance or contraindication to at least two oral weight-management drugs. It also required a preferred-product trial unless a documented exception applied. Other plan-specific steps can exist outside the public clinical policies reviewed.
How much weight must be lost to keep coverage?
All 20 coded Wegovy and Zepbound pathways required at least 5 percent loss from baseline body weight or maintenance of an initial 5 percent loss for continuation. Six pathways — three CVS Caremark and three Aetna — also required at least three months at a stable maintenance dose before continuation.
Does losing weight make a patient ineligible at renewal?
Not under the 14 pathways that explicitly preserve the pre-treatment BMI: all eight Cigna pathways, all three CVS Caremark pathways and all three Aetna pathways. Those documents direct reviewers to the BMI before GLP-1 therapy or at the start of any weight-loss drug therapy. The public UnitedHealthcare and FEP initiation branches do not state an equivalent universal instruction, so their exact plan documents must be checked.
How long does an initial GLP-1 authorization last?
Initial approvals ranged from five to eight months. Two pathways were five months, six were six months, one was seven months and eleven were eight months. Every renewal period in the 20-row dataset was 12 months.
Why might Ozempic be covered when Wegovy is not?
They usually follow different policies and indications. Ozempic is generally reviewed under a type 2 diabetes pathway, while Wegovy for chronic weight management is reviewed under an anti-obesity benefit that a plan may restrict or exclude. A plan can cover the diabetes pathway while excluding or making the weight-management pathway nonformulary.
Does Blue Cross Blue Shield have one nationwide GLP-1 rule?
No. Blue Cross Blue Shield companies are independent and locally operated. The Federal Employee Program is a distinct nationwide program with its own Wegovy and Zepbound criteria and should not be presented as the rule for every local Blue plan.
Can a drug have prior-authorization criteria and still be nonformulary?
Yes. Clinical criteria describe the conditions used in a coverage review; the formulary describes the drug’s coverage position. Aetna’s May 2026 Advanced Control formulary lists Wegovy as preferred brand with prior authorization and lists Zepbound as nonformulary, while Aetna separately publishes clinical criteria addressing both drugs. The two documents answer different questions.
How often do GLP-1 prior-authorization policies change?
There is no universal schedule. UnitedHealthcare’s current weight-loss document records six Pharmacy and Therapeutics approvals from March 2025 through April 2026. Aetna’s sampled formulary says it is updated in the first week of each month. Cigna’s current BMI-32 and BMI-35 policies became BEO005 and BEO006 effective June 1, 2026, replacing older identifiers that can still appear in search indexes.
What documentation do the reviewed policies ask for?
Recurring fields include height, weight and BMI; qualifying comorbidities; dates and components of lifestyle or weight-management participation; prior medications when a step applies; stable-dose history where required; and current weight for renewal. Separate indication branches add separate evidence, such as a sleep study for obstructive sleep apnea, cardiovascular history for cardiovascular-risk reduction, or fibrosis staging for MASH. This is a list of fields observed in the reviewed policies, not a universal checklist.
Primary-source ledger
| Code | Issuer document | Current status used | Retrieved |
|---|---|---|---|
| C1 | Cigna IP0206 — BMI ≥30 | Effective June 1, 2026 | July 31, 2026 |
| C2 | Cigna BEO005 — BMI ≥32 benefit-exclusion override | Effective June 1, 2026 | July 31, 2026 |
| C3 | Cigna BEO006 — BMI ≥35 benefit-exclusion override | Effective June 1, 2026 | July 31, 2026 |
| C4 | Cigna CNF684 — National Formulary weight-loss GLP-1 PA | Current public document; selected revisions through April 15, 2026 | July 31, 2026 |
| U1 | UnitedHealthcare Program 2026 P 1114-21 | Effective July 1, 2026 | July 31, 2026 |
| V1 | CVS Caremark 4774-C — Wegovy | P08-2025 v3 public criteria | July 31, 2026 |
| V2 | CVS Caremark 6192-C — Zepbound | P08-2025 public criteria | July 31, 2026 |
| A1 | Aetna 6450-C — Weight Loss BMI 35 | P08-2025 v8; page dated April 10, 2026 | July 31, 2026 |
| F1 | FEP 5.99.030 — Wegovy | Annual review approved June 11, 2026; effective July 1, 2026 | July 31, 2026 |
| F2 | FEP 5.99.031 — Zepbound formulary exclusion | Annual review approved June 11, 2026; effective July 1, 2026 | July 31, 2026 |
| M1 | CMS Medicare GLP-1 Bridge provider guidance | Page last modified July 13, 2026 | July 31, 2026 |
Source: Each linked issuing organization. Retrieval date: July 31, 2026.
Additional public documents used for interpretation
- Aetna May 2026 Advanced Control Plan formulary
- Cigna National Formulary diabetes GLP-1 policy
- UnitedHealthcare commercial diabetes GLP-1 policy
- CMS Medicare GLP-1 Bridge overview
- Cigna CNF908, disclosed near-duplicate BMI-32 template
- Cigna CNF950, disclosed near-duplicate BMI-35 template
- CarelonRx drug lists
- Blue Cross Blue Shield company structure
- Humana drug-list tools
- Kaiser Permanente drug-formulary lookup
Change log
| Date | Row or figure | Previous | Current | Reason |
|---|---|---|---|---|
| 2026-07-31 | Initial public dataset | — | 20 pathways in 10 documents across 5 organizations/programs | First full primary-source release using the documented row and deduplication rules |
Source: The RX Index dataset release record.
Related research
The RX Index Research publishes original, primary-sourced datasets on GLP-1 access and coverage. It is an independent research and reference resource. No sponsorship, product placement, affiliate links, or provider promotion appears on this page.