{
 "$schema": "https://glpchart.com/api/v1/schema/coverage.schema.json",
 "dataset": "coverage",
 "version": "1.0.0",
 "generated_at": "2026-11-05",
 "checked": "2026-08-28",
 "license": "CC BY 4.0",
 "license_url": "https://creativecommons.org/licenses/by/4.0/",
 "attribution": "according to GLP Chart",
 "source_url": "https://glpchart.com",
 "disclaimer": "Reference information, not medical or legal advice, and not a guarantee of coverage. Confirm the current policy with the insurer before relying on it.",
 "count": 67,
 "coverage": [
  {
   "slug": "aca-marketplace-glp1",
   "payer": "ACA Marketplace",
   "drug": "GLP-1 medications",
   "drug_full": "Wegovy, Zepbound, Saxenda for obesity",
   "plan_type": "ACA Marketplace individual and family plans you buy yourself, including Ambetter and Oscar",
   "status": "excluded",
   "answer": "Rarely for weight loss. When KFF read the drug lists of the federally run Marketplace plans, 1 percent covered Wegovy for weight loss and none covered Zepbound.",
   "employer_election": false,
   "policy_date": "2026-06-12",
   "indications": [
    {
     "label": "Obesity / weight management",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    }
   ],
   "sources": [
    {
     "url": "https://kff.org/affordable-care-act/costly-glp-1-drugs-are-rarely-covered-for-weight-loss-by-marketplace-plans/",
     "title": "KFF, Costly GLP-1 Drugs are Rarely Covered for Weight Loss by Marketplace Plans",
     "verified": "2026-06-12"
    }
   ],
   "url": "https://glpchart.com/coverage/aca-marketplace-glp1/"
  },
  {
   "slug": "aetna-mounjaro",
   "payer": "Aetna",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Aetna covers Mounjaro for type 2 diabetes once the plan signs off. Its pharmacy policy approves it if metformin did not work for you, if you cannot take metformin, or if you need combination therapy with an A1C of 7.5 percent or higher. Quantity limits apply. Aetna will not cover Mounjaro for weight loss, because the FDA approved it for type 2 diabetes only. The weight-loss version of the same drug, tirzepatide, is sold as Zepbound. That is a separate weight-loss benefit, and an employer has to choose to add it.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "5468-C",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/GIP-GLP-1_Agonist_Mounjaro_PA_with_Limit_Policy_5468-C_UDR_05-2024.html",
     "title": "GIP-GLP-1 Agonist Mounjaro PA with Limit Policy 5468-C: Pharmacy Clinical Policy Bulletins, Aetna Non-Medicare Prescription Drug Plan",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/aetna-mounjaro/"
  },
  {
   "slug": "aetna-ozempic",
   "payer": "Aetna",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Aetna covers Ozempic for type 2 diabetes once the plan signs off. That sign-off runs under policy 2439-C from CVS Caremark, the company that runs Aetna's drug benefit. You need a documented type 2 diabetes diagnosis, for example an A1C of 6.5 percent or higher. You also need one more qualifying factor. Metformin that did not work, that you could not tolerate, or that is not safe for you is one. Combination therapy with an A1C of 7.5 percent or higher is another. Established cardiovascular disease and chronic kidney disease each qualify on their own. The quantity limit is one pen per fill for once-weekly dosing, and an approval lasts 12 months. Ozempic is not covered for weight loss. That use belongs to Wegovy, the same semaglutide at a higher dose.",
   "employer_election": true,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": "Metformin that did not work, that you could not tolerate, or that is not safe for you is one qualifying path. Combination therapy with an A1C of 7.5 percent or higher is another. Established cardiovascular disease and chronic kidney disease each qualify on their own.",
     "continuation": null,
     "policy_number": "2439-C",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://info.caremark.com/content/dam/enterprise/caremark/microsites/dig/pdfs/pa_forms_default/2439-C_Ozempic.pdf",
     "title": "Antidiabetic GLP-1, GIP-GLP-1 Agonist PA with Limit 2439-C P05-2025 v4",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/aetna-ozempic/"
  },
  {
   "slug": "aetna-rybelsus",
   "payer": "Aetna",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Aetna covers Rybelsus for type 2 diabetes once the plan signs off, through CVS Caremark, the company that runs Aetna's drug benefit. You need a documented type 2 diabetes diagnosis. You also need one of these: metformin that did not work, that you could not tolerate, or that is not safe for you, or combination therapy with an A1C of 7.5% or greater. Rybelsus is not covered for weight loss. It has no weight-loss approval. The weight-loss semaglutide is Wegovy, and you take it as a shot.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "3318-C",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025%20commercial/GLP-1_Agonist_Rybelsus_PA_with_Limit_Policy_3318-C_UDR_05-2024.html",
     "title": "GLP-1 Agonist Rybelsus PA with Limit Policy 3318-C UDR 05-2024, Pharmacy Clinical Policy Bulletins, Aetna Non-Medicare Prescription Drug Plan",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/aetna-rybelsus/"
  },
  {
   "slug": "aetna-wegovy",
   "payer": "Aetna",
   "drug": "Wegovy",
   "drug_full": "Wegovy (semaglutide 2.4 mg)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Yes. Aetna covers Wegovy with prior authorization on its standard commercial drug plan, for both the obesity indication and the cardiovascular indication.",
   "employer_election": true,
   "policy_date": "2026-06-12",
   "indications": [
    {
     "label": "Obesity / chronic weight management",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher, or BMI 27 or higher with at least one weight-related comorbidity (type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea)",
     "step_therapy": "Six months in a comprehensive weight-management program (behavioral change, reduced-calorie diet, increased physical activity) before approval",
     "continuation": "At least 5 percent loss of baseline body weight within the first 3 months of therapy",
     "policy_number": "4774-C UDR 08-2023 v2",
     "confidence": "high",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Cardiovascular risk reduction (SELECT indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 27 or higher",
     "step_therapy": "None specified for the cardiovascular indication. The patient must be on appropriate cardiovascular guideline-directed medications or have a clinical reason for non-use.",
     "continuation": null,
     "policy_number": "6410-C UDR 03-2024",
     "confidence": "high",
     "verified_date": "2026-06-12"
    }
   ],
   "sources": [
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Wegovy_PA_with_Limit_4774-C_UDR_08-2023_v2.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Wegovy PA with Limit 4774-C UDR 08-2023 v2",
     "verified": "2026-06-12"
    },
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Wegovy_(Cardiovascular)_PA_with_Limit_6410-C_UDR_03-2024.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Wegovy (Cardiovascular) PA with Limit 6410-C UDR 03-2024",
     "verified": "2026-06-12"
    }
   ],
   "url": null
  },
  {
   "slug": "aetna-wegovy-zepbound",
   "payer": "Aetna",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide)",
   "plan_type": "Commercial non-Medicare (fully insured and self-funded employer plans)",
   "status": "split",
   "answer": "Yes for Wegovy, with prior authorization on Aetna's standard commercial formulary. Zepbound is a different story: CVS Caremark removed it from Aetna standard commercial formularies for weight loss effective July 1, 2025, so it is only covered with prior authorization on FE-Compatible plan types. Self-funded employers can set their own formulary and may cover or exclude either drug regardless of Aetna's standard policy.",
   "employer_election": true,
   "policy_date": "2026-06-18",
   "indications": [
    {
     "label": "Obesity / chronic weight management (Wegovy, all standard commercial plans)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher, or BMI 27 or higher with at least one weight-related comorbidity (type 2 diabetes, hypertension, dyslipidemia, or obstructive sleep apnea)",
     "step_therapy": "Six months in a comprehensive weight-management program (behavioral modification, reduced-calorie diet, increased physical activity) before approval",
     "continuation": "At least 5 percent loss of baseline body weight within the first 3 months of therapy at stable maintenance dosing",
     "policy_number": "4774-C UDR 08-2023 v2",
     "confidence": "high",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Cardiovascular risk reduction (Wegovy, SELECT indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 27 or higher",
     "step_therapy": "None specified for the cardiovascular indication. Patient must be on appropriate cardiovascular guideline-directed medications or have a clinical reason for non-use.",
     "continuation": null,
     "policy_number": "6410-C UDR 03-2024",
     "confidence": "high",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Obesity / weight management (Zepbound, FE-Compatible plans only)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher, or BMI 27 or higher with at least one weight-related comorbidity (type 2 diabetes, hypertension, dyslipidemia, OSA, or cardiovascular disease)",
     "step_therapy": "No step therapy through other agents is specified in policy 6947-C for FE-Compatible plans. The six-month lifestyle program documentation is required.",
     "continuation": "At least 5 percent loss of baseline body weight within the first 3 months of therapy",
     "policy_number": "6947-C P04-2025",
     "confidence": "high",
     "verified_date": "2026-06-18"
    },
    {
     "label": "Obesity / weight management (Zepbound, standard commercial plans)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "6981-A P04-2025",
     "confidence": "high",
     "verified_date": "2026-06-18"
    }
   ],
   "sources": [
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Wegovy_PA_with_Limit_4774-C_UDR_08-2023_v2.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Wegovy PA with Limit 4774-C UDR 08-2023 v2",
     "verified": "2026-06-12"
    },
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Wegovy_(Cardiovascular)_PA_with_Limit_6410-C_UDR_03-2024.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Wegovy (Cardiovascular) PA with Limit 6410-C UDR 03-2024",
     "verified": "2026-06-12"
    },
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Zepbound_PA_with_Limit_FE_Compatible_6947-C_P04-2025.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Zepbound PA with Limit FE Compatible 6947-C P04-2025 (effective July 1, 2025)",
     "verified": "2026-06-18"
    },
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Zepbound_Exception_(ACCF,_ACF,_ACFC,_SCCF,_SF,_SFC,_VF,_VFC)_6981-A_P04-2025.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Zepbound Exception Policy 6981-A P04-2025 (effective July 1, 2025)",
     "verified": "2026-06-18"
    }
   ],
   "url": null
  },
  {
   "slug": "aetna-zepbound",
   "payer": "Aetna",
   "drug": "Zepbound",
   "drug_full": "Zepbound (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "varies-by-plan",
   "answer": "Aetna covers Zepbound for weight loss on the plans it calls FE-Compatible. You need a BMI of 30, or 27 with a weight-related condition. Those plans also ask for six months in a structured weight-management program. On its standard commercial plans Zepbound is not on the drug list at all. Aetna dropped it from those lists on July 1, 2025. CVS Caremark, the company that runs Aetna's drug benefit, made that cut and named Wegovy the preferred weight-loss GLP-1. To get Zepbound on a standard plan you need a formulary exception, and you have to try Wegovy first.",
   "employer_election": true,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Obesity / weight management (FE-Compatible plans)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher. BMI 27 or higher also qualifies with at least one weight-related condition: type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, or cardiovascular disease",
     "step_therapy": "None. Policy 6947-C names no other drug you have to try first on FE-Compatible plans.",
     "continuation": "At least 5 percent loss of baseline body weight within the first 3 months of therapy",
     "policy_number": "6947-C P04-2025",
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Obesity / weight management (standard commercial plans, non-formulary, exception required)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-18"
    },
    {
     "label": "Obstructive sleep apnea (SURMOUNT-OSA indication, FE-Compatible plans)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": null,
     "continuation": null,
     "policy_number": "6947-C P04-2025",
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Zepbound_PA_with_Limit_FE_Compatible_6947-C_P04-2025.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Zepbound PA with Limit FE Compatible 6947-C P04-2025 (effective July 1, 2025)",
     "verified": "2026-11-04"
    },
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Zepbound_Exception_(ACCF,_ACF,_ACFC,_SCCF,_SF,_SFC,_VF,_VFC)_6981-A_P04-2025.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Zepbound Exception Policy 6981-A P04-2025 (effective July 1, 2025)",
     "verified": "2026-06-18"
    },
    {
     "url": "https://www.aetna.com/products/rxnonmedicare/data/2025/Zepbound_PA_with_Limit_FE_Compatible_6947-C_P04-2025.html",
     "title": "Aetna Non-Medicare Prescription Drug Plan, Zepbound PA with Limit FE Compatible 6947-C P04-2025 (effective July 1, 2025)",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/aetna-zepbound/"
  },
  {
   "slug": "ambetter-mounjaro",
   "payer": "Ambetter (Centene)",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "varies-by-plan",
   "answer": "Yes for type 2 diabetes, in the states where Mounjaro is on the plan's drug list. The plan has to sign off, and you have to try other drugs first. Some state drug lists leave it off entirely. Ambetter marketplace plans run on Centene policy CP.PMN.183, which treats Mounjaro (tirzepatide) as a non-preferred agent. Approval needs a type 2 diabetes diagnosis, an A1C at or above 7 percent after at least 3 months on metformin, and a written record that the plan's preferred GLP-1 drugs failed first. Ambetter will not cover Mounjaro for weight loss. The FDA approved Mounjaro for type 2 diabetes only. The tirzepatide approved for weight loss is Zepbound, and Ambetter marketplace plans exclude it outside California.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": "Yes. A member needs at least a 3 month trial of metformin with an A1C at or above 7 percent. A member who has never taken metformin qualifies at an A1C at or above 8.5 percent, starting the two together. Mounjaro is a non-preferred GLP-1 agent, so the current master policy also requires the preferred GLP-1 drugs to fail first. That is at least 3 months in a row on liraglutide (Victoza), then the same on Trulicity. The step is waived where each is contraindicated, or caused clinically significant adverse effects. The older marketplace version required a failure of Victoza, Trulicity and Ozempic before Mounjaro.",
     "continuation": null,
     "policy_number": "CP.PMN.183",
     "confidence": "high",
     "verified_date": "2026-08-27"
    },
    {
     "label": "Weight loss / chronic weight management",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "CP.PMN.298",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/policies/pharmacy-policies/pmn/CP.PMN.183.pdf",
     "title": "Centene Clinical Policy: Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists, Reference Number CP.PMN.183, Effective Date 09.19.18, Last Review Date 02.26, section I.A Type 2 Diabetes Mellitus",
     "verified": "2026-08-27"
    },
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/ambetteril/policy-notifications/CP.PMN.298%20Tirzepatide%20(Zepbound)%2002.07.25.pdf",
     "title": "Centene Clinical Policy: Tirzepatide (Zepbound), Reference Number CP.PMN.298, section I.B and II.B, read alongside the Mounjaro prescribing information (Lilly, January 2026) confirming a type 2 diabetes indication only",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/ambetter-mounjaro/"
  },
  {
   "slug": "ambetter-ozempic",
   "payer": "Ambetter (Centene)",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Ambetter marketplace plans cover Ozempic for type 2 diabetes once the plan signs off. Ozempic sits on Ambetter's preferred GLP-1 list. So the plan asks for a documented type 2 diabetes diagnosis and an age of 18 or older. It also asks that you take no other GLP-1 at the same time, and that the dose stay within the FDA-approved maximum. Ambetter will not cover Ozempic for weight loss, because the FDA approved it for type 2 diabetes only. Wegovy is the weight-loss semaglutide. Most Ambetter marketplace plans leave weight-loss GLP-1s out of the benefits.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "HIM.PA.53",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/policies/pharmacy-policies/him/HIM.PA.53.pdf",
     "title": "Clinical Policy: Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (HIM.PA.53)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/ambetter-ozempic/"
  },
  {
   "slug": "ambetter-rybelsus",
   "payer": "Ambetter (Centene)",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Ambetter marketplace plans cover Rybelsus for type 2 diabetes once the plan signs off. Rybelsus sits on Ambetter's preferred GLP-1 list. So the plan asks for a documented type 2 diabetes diagnosis and an age of 18 or older. It also asks that you take no other GLP-1 at the same time, and that the dose stay within the FDA-approved maximum. Ambetter will not cover Rybelsus for weight loss, because the FDA approved it for type 2 diabetes only. Wegovy is the weight-loss semaglutide. Most Ambetter marketplace plans leave weight-loss GLP-1s out of the benefits.",
   "employer_election": false,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "HIM.PA.53",
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/policies/pharmacy-policies/him/HIM.PA.53.pdf",
     "title": "Clinical Policy: Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists (HIM.PA.53)",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/ambetter-rybelsus/"
  },
  {
   "slug": "ambetter-wegovy-zepbound",
   "payer": "Ambetter (Centene)",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide)",
   "plan_type": "ACA Marketplace individual and family plans you buy yourself, sold under the Ambetter brand in 29 states",
   "status": "split",
   "answer": "No for weight loss in most states, and yes for a short list of other diagnoses. The Wegovy policy calls weight management \"a benefit exclusion\" that \"will not be authorized.\" The Zepbound policy uses the same words. That same Wegovy policy does cover the drug to lower cardiovascular risk, and for MASH, a liver disease, once fibrosis is moderate to advanced. The Zepbound policy does cover Zepbound for moderate to severe sleep apnea. Each of those routes needs the plan to sign off first. California is the exception. Ambetter there is sold as Ambetter from Health Net. Its drug list says most plans do cover weight-loss medications after a sign-off, and the criteria set a marketplace threshold of BMI 40 or higher.",
   "employer_election": false,
   "policy_date": "2026-08-15",
   "indications": [
    {
     "label": "Obesity / chronic weight management (Wegovy)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "CP.PMN.295",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obesity / chronic weight management (Zepbound)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "CP.PMN.298",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Cardiovascular risk reduction (Wegovy, SELECT indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 27 or higher",
     "step_therapy": "Only for members who also have type 2 diabetes. Those requests need at least 3 months in a row on each of three drugs: Ozempic or Rybelsus, Trulicity, and liraglutide (generic Victoza). The step is waived if all three are contraindicated, or if they caused clinically significant adverse effects. Switching to Wegovy from another GLP-1 needs a medical reason. The policy says gut side effects do not count as one.",
     "continuation": "First renewal requires at least 5 percent loss of baseline body weight. Second and later renewals require that the member has lost weight and/or maintained weight loss on therapy.",
     "policy_number": "CP.PMN.295",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Metabolic dysfunction-associated steatohepatitis (Wegovy injection)",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": "The same three-drug diabetes step applies to members who also have type 2 diabetes. That is 3 months in a row on each of Ozempic or Rybelsus, Trulicity, and liraglutide (generic Victoza).",
     "continuation": "After at least 12 months on the drug, one of three. Fibrosis improved by at least 1 stage with no worsening of MASH. Or MASH resolved with no worsening of fibrosis. Or no rise in fibrosis stage and no worsening of MASH from baseline.",
     "policy_number": "CP.PMN.295",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obstructive sleep apnea (Zepbound, SURMOUNT-OSA indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": "Only for members who also have type 2 diabetes. Those requests need 3 months in a row on each of Ozempic or Rybelsus, Trulicity, and Victoza. The step is waived if all are contraindicated, or if they caused side effects the policy calls clinically significant.",
     "continuation": "First renewal needs at least 5 percent loss of baseline body weight, plus one measured sleep result. That can be a lower apnea-hypopnea index than at the start. Or a better score on the sleep apnea-specific hypoxic burden. Or a better score on a sleep-related patient reported outcome. Later renewals need weight lost or kept off, plus one of those three holding steady or improving.",
     "policy_number": "CP.PMN.298",
     "confidence": "medium",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obesity / chronic weight management (California, Ambetter from Health Net)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 40 or higher for marketplace plans. The same policy sets BMI 30 or higher for small group and for large group enhanced coverage. BMI 27 or higher also works there, with a sign of raised cardiovascular risk or another condition tied to obesity. Members aged 12 to 17 qualify at a BMI at or above the 95th percentile for their age and sex",
     "step_therapy": null,
     "continuation": "First renewal requires at least 5 percent loss of baseline body weight.",
     "policy_number": "HNCA.CP.CPA.352 (Wegovy) and HNCA.CP.CPA.359 (Zepbound)",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obstructive sleep apnea (California, Ambetter from Health Net)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": "For members who also have type 2 diabetes, 3 months in a row on each of four drugs: Ozempic or Rybelsus, Trulicity, liraglutide (generic Victoza), and Mounjaro. That is one drug more than the Centene marketplace version.",
     "continuation": null,
     "policy_number": "HNCA.CP.CPA.359",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Formulary placement on the 2026 Ambetter state drug lists",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    }
   ],
   "sources": [
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/policies/pharmacy-policies/pmn/CP.PMN.295.pdf",
     "title": "Centene Clinical Policy CP.PMN.295, Semaglutide (Wegovy), sections I.B and II.B",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/ambetteril/policy-notifications/CP.PMN.298%20Tirzepatide%20(Zepbound)%2002.07.25.pdf",
     "title": "Clinical Policy: Tirzepatide (Zepbound), Reference Number CP.PMN.298, Effective Date 12.20.24, Last Review Date 02.25, Line of Business HIM and Medicaid, section I.B and section II.B",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/policies/pharmacy-policies/pmn/CP.PMN.295.pdf",
     "title": "Clinical Policy: Semaglutide (Wegovy), Reference Number CP.PMN.295, Last Review Date 05.26, section I.A Cardiovascular Event Prevention and section II.A Continued Therapy",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/policies/pharmacy-policies/pmn/CP.PMN.295.pdf",
     "title": "Clinical Policy: Semaglutide (Wegovy), Reference Number CP.PMN.295, Last Review Date 05.26, section I.C and section II.C Metabolic Dysfunction-Associated Steatohepatitis",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.ambetterhealth.com/content/dam/centene/ambetteril/policy-notifications/CP.PMN.298%20Tirzepatide%20(Zepbound)%2002.07.25.pdf",
     "title": "Clinical Policy: Tirzepatide (Zepbound), Reference Number CP.PMN.298, Effective Date 12.20.24, Last Review Date 02.25, section I.A and section II.A Obstructive Sleep Apnea",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.healthnet.com/content/dam/centene/healthnet/pdfs/provider/ca/policies/HNCA.CP.CPA.352.pdf",
     "title": "Health Net of California Clinical Policy: Semaglutide (Wegovy), Reference Number HNCA.CP.CPA.352, Last Review Date 03.26, Line of Business Commercial and HIM, section I.A Weight Management and its BMI table",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.healthnet.com/content/dam/centene/healthnet/pdfs/provider/ca/policies/HNCA.CP.CPA.359.pdf",
     "title": "Health Net of California Clinical Policy: Tirzepatide (Zepbound), Reference Number HNCA.CP.CPA.359, Effective Date 09.24, Last Review Date 07.01.26, Line of Business Commercial and HIM, section I.B Obstructive Sleep Apnea",
     "verified": "2026-08-15"
    },
    {
     "url": "https://ambetter.sunshinehealth.com/content/dam/centene/Sunshine/Ambetter/PDFs/2026-fl-formulary.pdf",
     "title": "Ambetter from Sunshine Health 2026 Formulary, effective January 1 2026, document code AMB25-FL-C-00023, formulary introduction and the ADHD/anti-narcolepsy/anti-obesity/anorexiants section",
     "verified": "2026-08-15"
    }
   ],
   "url": "https://glpchart.com/coverage/ambetter-wegovy-zepbound/"
  },
  {
   "slug": "anthem-mounjaro",
   "payer": "Anthem Blue Cross and Blue Shield (Elevance Health)",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Anthem covers Mounjaro for type 2 diabetes once the plan signs off. A quantity limit applies. On one 2025 Anthem drug list the medicine sits on Tier 2, which costs more than a generic, but the tier varies by employer plan. Anthem will not cover Mounjaro for weight loss, because the FDA approved it for type 2 diabetes only. The weight-loss version of the same drug, tirzepatide, is Zepbound. Anthem looks at Zepbound under a different policy, one written for weight loss.",
   "employer_election": true,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "medium",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://fm.formularynavigator.com/FBO/143/2025_Select_4_Tier_ME_IND.pdf",
     "title": "Anthem 2025 Select Drug List (Four Tier), Maine, effective 12/01/2025",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/anthem-mounjaro/"
  },
  {
   "slug": "anthem-ozempic",
   "payer": "Anthem Blue Cross and Blue Shield (Elevance Health)",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Anthem commercial plans cover Ozempic for type 2 diabetes once the plan signs off. One published Anthem prescribing policy asks for a documented type 2 diabetes diagnosis. It then asks for a trial of metformin, or a reason metformin is not safe for you, or a history of heart or artery disease caused by plaque. The policy calls that last one atherosclerotic cardiovascular disease. The exact criteria and the drug list still vary by employer plan. Anthem will not cover Ozempic for weight loss. Its member benefits generally leave weight-loss drugs out, and the FDA approved Ozempic for type 2 diabetes only. Wegovy is the same medicine, semaglutide, at a higher dose approved for weight loss, and it sits under separate weight-loss coverage rules.",
   "employer_election": true,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "KYBCBS-CM-025647-23",
     "confidence": "medium",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://providernews.anthem.com/kentucky/articles/network-alert-prescribing-glucagon-like-peptide-1-glp-1-r-13334",
     "title": "Network alert: Prescribing glucagon-like peptide-1 (GLP-1) receptor agonists (Anthem Blue Cross and Blue Shield, Commercial)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/anthem-ozempic/"
  },
  {
   "slug": "anthem-rybelsus",
   "payer": "Anthem Blue Cross and Blue Shield (Elevance Health)",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Anthem commercial plans cover Rybelsus for type 2 diabetes once the plan signs off. Anthem's published commercial prescribing policy asks for a documented type 2 diabetes diagnosis. It then asks for a trial of metformin, or a reason metformin is not safe for you, or a history of heart or artery disease caused by plaque. The policy calls that last one atherosclerotic cardiovascular disease. The exact criteria and the covered drug list still vary by employer plan. Anthem will not cover Rybelsus for weight loss. Its member benefits generally leave weight-loss drugs out, and the FDA approved Rybelsus for type 2 diabetes only. Wegovy is the semaglutide approved for weight loss, and it sits under separate weight-loss coverage rules.",
   "employer_election": true,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "KYBCBS-CM-025647-23",
     "confidence": "medium",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://providernews.anthem.com/kentucky/articles/network-alert-prescribing-glucagon-like-peptide-1-glp-1-r-13334",
     "title": "Network alert: Prescribing glucagon-like peptide-1 (GLP-1) receptor agonists (Anthem Blue Cross and Blue Shield, Commercial)",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/anthem-rybelsus/"
  },
  {
   "slug": "anthem-wegovy-zepbound",
   "payer": "Anthem Blue Cross and Blue Shield (Elevance Health)",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide)",
   "plan_type": "Commercial job-based and individual plans across the Anthem and Elevance states",
   "status": "varies-by-plan",
   "answer": "Yes on some plans, and Anthem flags this on the drug list itself. Wegovy and Zepbound both sit at Tier 2 on Anthem's commercial drug lists. Both carry three codes: PA, QL and BE. BE is Anthem's code for a benefit exclusion, and its own code list adds \"This drug may not be covered depending on your plans design.\" Anthem does not publish the rules it applies to a commercial request for these two drugs. So we cannot show you a sourced BMI number.",
   "employer_election": true,
   "policy_date": "2026-08-15",
   "indications": [
    {
     "label": "Obesity / chronic weight management (commercial, subject to the benefit exclusion flag)",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": "Not published. Anthem's commercial drug lists show a PA code on both drugs, and no ST code. That points to a sign-off with no formal step-therapy rule on these list versions.",
     "continuation": null,
     "policy_number": null,
     "confidence": "medium",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Commercial drug list changes (California lists narrowing, national lists adding Wegovy tablet)",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Weight loss (Anthem Blue Cross Medi-Cal, California Medicaid)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    }
   ],
   "sources": [
    {
     "url": "https://fm.formularynavigator.com/FBO/143/National_Drug_List_3_Tier_ABC.pdf",
     "title": "Anthem Blue Cross National Drug List, Three Tier Drug Plan (DMHC filing, last updated January 1, 2025), anti-obesity GLP-1 and GIP/GLP-1 receptor agonist entries and the drug list code legend",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.anthem.com/content/dam/digital/docs/pharmacy-information/unbranded-formulary-update-quarterlyrolling-anthem.pdf",
     "title": "Anthem Formulary Update, rolling quarterly commercial drug list changes (Q4 2026 back through 2025), published at anthem.com",
     "verified": "2026-08-15"
    },
    {
     "url": "https://providers.anthem.com/docs/gpp/california-provider/CA_MMP_GLP1Coverage.pdf",
     "title": "Anthem Blue Cross, GLP-1 Coverage Considerations, November 14, 2025 (Medi-Cal Rx), document CA-BC-CD-001363-25-S604",
     "verified": "2026-08-15"
    }
   ],
   "url": "https://glpchart.com/coverage/anthem-wegovy-zepbound/"
  },
  {
   "slug": "bcbs-illinois-mounjaro",
   "payer": "Blue Cross and Blue Shield of Illinois",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "BCBS Illinois covers Mounjaro (tirzepatide) for type 2 diabetes on its 2026 commercial drug list. The plan has to sign off, and quantity limits apply. The sign-off criteria require that the patient has already tried a diabetes drug, so a first-line drug like metformin usually comes first. BCBSIL will not cover Mounjaro for weight loss. Zepbound is the weight-loss tirzepatide. BCBSIL lists it separately, and covers it only where the employer group bought a weight-loss benefit.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "23466.0726",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.bcbsil.com/docs/provider/rx-drugs/il/rx-um-program-clinical-criteria-il.pdf",
     "title": "BCBSIL Prior Authorization/Step Therapy Program, GLP-1 Agonists, July 2026",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/bcbs-illinois-mounjaro/"
  },
  {
   "slug": "bcbs-illinois-ozempic",
   "payer": "Blue Cross and Blue Shield of Illinois",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "BCBS Illinois covers Ozempic for type 2 diabetes on its 2026 commercial drug lists. It sits there as a preferred brand. The plan has to sign off, and a quantity limit of one pen every 28 days applies. Approval needs a documented type 2 diabetes diagnosis, and it runs 12 months before it has to be renewed. BCBSIL does not cover Ozempic for weight loss, because the FDA approved it for type 2 diabetes only. Wegovy is the semaglutide for weight loss. It is a separate product at a higher dose, with rules of its own.",
   "employer_election": false,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://www.bcbsil.com/il/documents/rx-drugs/drug-lists/balanced-il-2026.pdf",
     "title": "BCBSIL Balanced Drug List, October 2026 edition (HCSC, Prime Therapeutics). Ozempic pens listed as preferred brand (P) with PA and QL of 1 pen per 28 days.",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/bcbs-illinois-ozempic/"
  },
  {
   "slug": "bcbs-illinois-rybelsus",
   "payer": "Blue Cross and Blue Shield of Illinois",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "BCBS Illinois covers Rybelsus for type 2 diabetes once the plan signs off. Prime Therapeutics, the pharmacy benefit manager for BCBS Illinois, runs that sign-off. Approval needs a documented type 2 diabetes diagnosis, and an earlier trial of another drug for diabetes. Quantity limits apply. Rybelsus is not covered for weight loss, because the FDA approved it for type 2 diabetes only. Wegovy is the semaglutide for weight loss, and BCBS Illinois lists it separately with a sign-off of its own.",
   "employer_election": false,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "23466.0726",
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://www.bcbsil.com/docs/provider/rx-drugs/il/rx-um-program-clinical-criteria-il.pdf",
     "title": "BCBSIL Prior Authorization/Step Therapy Program, GLP-1 (glucagon-like peptide-1) Agonists clinical criteria 23466.0726",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/bcbs-illinois-rybelsus/"
  },
  {
   "slug": "bcbs-illinois-wegovy",
   "payer": "Blue Cross and Blue Shield of Illinois",
   "drug": "Wegovy",
   "drug_full": "Wegovy (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "varies-by-plan",
   "answer": "Yes on some plans. BCBSIL runs its drug benefit through Prime Therapeutics, its pharmacy benefit manager. Weight-loss and GLP-1 coverage is an optional benefit, and each employer group chooses to add it or leave it out. Many plans leave weight-loss drugs out of the benefit entirely. Where an employer did add it, Wegovy is covered once the plan signs off. The usual bar is a BMI of 30 or higher, or 27 or higher with a weight-related condition. You also need a written record of diet and lifestyle effort. Check with your plan or your employer before you assume weight-loss drugs are in.",
   "employer_election": true,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Obesity / weight management",
     "status": "excluded",
     "bmi_threshold": "30, or 27 with a weight-related condition",
     "step_therapy": "Varies by plan. Some plans require a written record of earlier weight-loss drugs",
     "continuation": null,
     "policy_number": null,
     "confidence": "medium",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://www.bcbsil.com/provider/education/education-reference/news/2024/08-12-2024-30-day-supply-limit",
     "title": "Pharmacy Benefit for GLP-1 and/or Anti-Obesity Drug Therapy",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/bcbs-illinois-wegovy/"
  },
  {
   "slug": "bcbs-illinois-zepbound",
   "payer": "Blue Cross and Blue Shield of Illinois",
   "drug": "Zepbound",
   "drug_full": "Zepbound (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "varies-by-plan",
   "answer": "Yes on some plans. BCBSIL runs its drug benefit through Prime Therapeutics. What the group bought decides whether weight-management drugs are in, and many groups leave them out. Where the benefit is in, Zepbound needs the plan to sign off. The bar is a BMI of 30 or higher, or 27 or higher with a weight-related condition. You also need at least 6 months of a reduced-calorie diet, more physical activity, and work on changing habits. Zepbound is covered too for moderate to severe obstructive sleep apnea in adults with obesity. That one is reviewed as a separate medical use.",
   "employer_election": true,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Obesity / chronic weight management",
     "status": "varies-by-plan",
     "bmi_threshold": "30 or higher, or 27 or higher with at least one weight-related condition. 25 or higher for adults of South Asian, Southeast Asian, or East Asian descent",
     "step_therapy": null,
     "continuation": null,
     "policy_number": "Choice_Commercial_PS_Weight_Management_PAQL_ProgSum_07-01-2026_v4",
     "confidence": "high",
     "verified_date": "2026-08-28"
    },
    {
     "label": "Moderate-to-severe obstructive sleep apnea in adults with obesity",
     "status": "covered-with-PA",
     "bmi_threshold": "30 or higher",
     "step_therapy": null,
     "continuation": null,
     "policy_number": "Choice_Commercial_PS_Weight_Management_PAQL_ProgSum_07-01-2026_v4",
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://web.primetherapeutics.com/provider/external/commercial/common/doc/en-us/Accord_Clinical_Criteria_Choice_Weight_Management.pdf",
     "title": "Weight Management Prior Authorization with Quantity Limit Program Summary (Prime Therapeutics, effective 07-01-2026)",
     "verified": "2026-08-28"
    },
    {
     "url": "https://web.primetherapeutics.com/provider/external/commercial/common/doc/en-us/Accord_Clinical_Criteria_Choice_Weight_Management.pdf",
     "title": "Weight Management Prior Authorization with Quantity Limit Program Summary (Prime Therapeutics, effective 07-01-2026)",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/bcbs-illinois-zepbound/"
  },
  {
   "slug": "bcbs-south-carolina-zepbound-osa",
   "payer": "BlueCross BlueShield of South Carolina",
   "drug": "Zepbound",
   "drug_full": "Zepbound (tirzepatide)",
   "plan_type": "Commercial",
   "status": "covered-with-PA",
   "answer": "Yes, for sleep apnea. BlueCross BlueShield of South Carolina covers Zepbound for moderate to severe obstructive sleep apnea, once the plan signs off. Weight loss alone does not qualify.",
   "employer_election": false,
   "policy_date": "2026-06-12",
   "indications": [
    {
     "label": "Obstructive sleep apnea (SURMOUNT-OSA indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": "The policy does not require a CPAP trial first.",
     "continuation": null,
     "policy_number": "CAM 922HB",
     "confidence": "high",
     "verified_date": "2026-06-12"
    }
   ],
   "sources": [
    {
     "url": "https://www.southcarolinablues.com/web/public/brands/medicalpolicyhb/external-policies/zepbound-tirzepatide-for-obstructive-sleep-apnea/",
     "title": "BlueCross BlueShield of South Carolina, Zepbound (tirzepatide) for Obstructive Sleep Apnea (Policy CAM 922HB)",
     "verified": "2026-06-12"
    }
   ],
   "url": "https://glpchart.com/coverage/bcbs-south-carolina-zepbound-osa/"
  },
  {
   "slug": "blue-shield-ca-mounjaro",
   "payer": "Blue Shield of California",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Blue Shield of California covers Mounjaro for type 2 diabetes under its commercial pharmacy benefit. Mounjaro is tirzepatide. The plan has to sign off, and you have to try other drugs first. You need a confirmed type 2 diabetes diagnosis, for example an A1C of 6.5% or higher. You need a documented problem with metformin, or a need for combination therapy at an A1C of 7.5% or higher. And you need two preferred GLP-1 agents to have failed you, or to have given you a side effect you could not live with. Ozempic, Trulicity, Victoza and Rybelsus are preferred agents. The FDA approved Mounjaro for type 2 diabetes only, so Blue Shield does not cover it for weight loss. Zepbound is the tirzepatide approved for weight loss, and it is reviewed under a policy of its own.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.blueshieldca.com/bin/cms/bsca/services/portal/provider/StreamDocumentServlet?fileName=PRV_Mounjaro_COMMext.pdf",
     "title": "Mounjaro - Commercial: BSC Medication Policy to Determine Medical Necessity",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/blue-shield-ca-mounjaro/"
  },
  {
   "slug": "blue-shield-ca-ozempic",
   "payer": "Blue Shield of California",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Blue Shield of California covers Ozempic for type 2 diabetes once the plan signs off. Ozempic is semaglutide. On the commercial drug list it sits at Tier 2, with a sign-off and quantity limits. The medical necessity policy also requires step therapy. You need a confirmed type 2 diabetes diagnosis, for example an A1C of 6.5% or higher. You then need a record that metformin did not work well enough, gave you a side effect you could not live with, or is not safe for you. Two other routes count instead of the metformin record. One is a need for combination therapy with an A1C of 7.5% or higher. The other is high-risk atherosclerotic cardiovascular disease. Ozempic is not covered for weight loss, because the FDA approved it for type 2 diabetes only. Wegovy is the semaglutide for weight loss, and it comes at a higher dose.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.blueshieldca.com/bin/cms/bsca/services/portal/provider/StreamDocumentServlet?fileName=PRV_GLP-1_COMMext.pdf",
     "title": "Glucagon-Like Peptide-1 (GLP-1) Agents, Commercial: BSC Medication Policy to Determine Medical Necessity (effective 5/3/2023)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/blue-shield-ca-ozempic/"
  },
  {
   "slug": "blue-shield-ca-rybelsus",
   "payer": "Blue Shield of California",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Blue Shield of California covers Rybelsus for type 2 diabetes once the plan signs off. Rybelsus is semaglutide you take by mouth. The commercial GLP-1 policy lists it as a preferred GLP-1 agent. It requires a confirmed type 2 diabetes diagnosis, for example an A1C of 6.5% or higher. It also requires step therapy through metformin. You have to show that metformin did not work well enough, gave you a side effect you could not live with, or is not safe for you. The one way around that step is a need for combination therapy at an A1C of 7.5% or higher. Rybelsus is not covered for weight loss, because the FDA approved it for type 2 diabetes only. Wegovy is the semaglutide for weight loss.",
   "employer_election": false,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://www.blueshieldca.com/bin/cms/bsca/services/portal/provider/StreamDocumentServlet?fileName=PRV_GLP-1_COMMext.pdf",
     "title": "Glucagon-Like Peptide-1 (GLP-1) Agents, Commercial: BSC Medication Policy to Determine Medical Necessity (effective 5/3/2023)",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/blue-shield-ca-rybelsus/"
  },
  {
   "slug": "blue-shield-ca-wegovy",
   "payer": "Blue Shield of California",
   "drug": "Wegovy",
   "drug_full": "Wegovy (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "varies-by-plan",
   "answer": "Yes on some plans. Blue Shield of California lists Wegovy on its weight management agents pharmacy policy. Where a plan includes the weight-loss drug benefit, Wegovy is covered for long-term weight management once the plan signs off. The policy sets a body mass index of 30 or higher. A BMI of 27 or higher also works, if you have a weight-related condition such as hypertension, type 2 diabetes, dyslipidemia, or sleep apnea treated with CPAP. It also requires at least 6 months in the past year of a reduced-calorie diet, more physical activity, and a behavior-change program. Whether the drug is covered at all turns on the member's benefit. Many commercial and self-funded employer plans exclude weight-loss drugs. Blue Shield's own policy says the member's specific benefit may affect drug coverage. To renew it you need to have lost at least 5% of your starting weight.",
   "employer_election": true,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Obesity / weight management",
     "status": "covered-with-PA",
     "bmi_threshold": "30, or 27 with a weight-related condition",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/2023/November/PRV_Weight-Management-Agents-PROVIDER.pdf",
     "title": "Weight Management Agents: Blue Shield of California pharmacy benefit drug policy (effective 09/27/2023, last revised 11/29/2023)",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/blue-shield-ca-wegovy/"
  },
  {
   "slug": "blue-shield-ca-zepbound",
   "payer": "Blue Shield of California",
   "drug": "Zepbound",
   "drug_full": "Zepbound (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "varies-by-plan",
   "answer": "Yes on some plans. Blue Shield of California runs a Weight Management Agents pharmacy policy, and it lists Zepbound as covered for long-term weight management in adults. Whether weight-loss drugs are covered at all turns on the member's employer group. Where the group has bought the benefit, Zepbound needs the plan to sign off. The bar is a BMI of 30 or higher. A BMI of 27 or higher also works with a weight-related condition, such as hypertension, type 2 diabetes, dyslipidemia, or sleep apnea treated with CPAP. You also need a written record of a full lifestyle program for at least 6 months in the past year. That means a reduced-calorie diet, more physical activity, and work on changing habits. To renew it you need to have lost at least 5% of your starting weight. The policy writes no separate obstructive sleep apnea route for Zepbound. Obstructive sleep apnea counts only as a qualifying condition under the BMI 27 route.",
   "employer_election": true,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Obesity / chronic weight management (adults)",
     "status": "covered-with-PA",
     "bmi_threshold": "30 or higher, or 27 or higher with a weight-related condition",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://www.blueshieldca.com/content/dam/bsca/en/provider/docs/2023/November/PRV_Weight-Management-Agents-PROVIDER.pdf",
     "title": "Weight Management Agents - Pharmacy Benefit Drug Policy, effective September 27, 2023 (4 pages; Zepbound listed with Wegovy, Saxenda, Qsymia, Contrave and Xenical)",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/blue-shield-ca-zepbound/"
  },
  {
   "slug": "cigna-mounjaro",
   "payer": "Cigna / Express Scripts",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Cigna and Express Scripts cover Mounjaro for type 2 diabetes. The plan has to sign off first, under Cigna National Formulary policy CNF749. Approval runs for one year at a time. You have to be 18 or older. Cigna will not cover Mounjaro for weight loss. The policy says weight loss without type 2 diabetes is not covered. For weight loss, the covered drug is Zepbound. It is the same tirzepatide, approved by the FDA for obesity.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "CNF749",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_749_coveragepositioncriteria_diabetes_mounjaro_pa.pdf",
     "title": "Cigna National Formulary Coverage Policy CNF749: Diabetes - Mounjaro Prior Authorization Policy",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/cigna-mounjaro/"
  },
  {
   "slug": "cigna-ozempic",
   "payer": "Cigna / Express Scripts",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Cigna covers Ozempic for type 2 diabetes if you are 18 or older. The plan has to sign off first. Approvals run for one year at a time. Cigna will not cover Ozempic for weight loss. It is not FDA-approved for that, and the policy calls it not medically necessary. That use belongs to Wegovy, the same semaglutide at a higher dose. Your tier, your copay and any step therapy or quantity limits come from your employer's benefit document. Check myCigna or your plan documents.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "CNF 360",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_360_coveragepositioncriteria_glucagon-like_peptide-1_agonists_pa.pdf",
     "title": "Glucagon-Like Peptide-1 Agonists Prior Authorization Policy (Cigna National Formulary Coverage, CNF 360)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/cigna-ozempic/"
  },
  {
   "slug": "cigna-rybelsus",
   "payer": "Cigna / Express Scripts",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Cigna covers Rybelsus for type 2 diabetes through Express Scripts. The plan has to sign off first. Approval runs for one year at a time. You have to be 18 or older. The standard rules do not require step therapy or a minimum A1C. Rybelsus is not covered for weight loss. It is FDA-approved for type 2 diabetes only. The weight-loss semaglutide is Wegovy. It runs under its own Cigna policy.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "CNF 360",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_360_coveragepositioncriteria_glucagon-like_peptide-1_agonists_pa.pdf",
     "title": "Diabetes: Glucagon-Like Peptide-1 Agonists Prior Authorization Policy (CNF 360)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/cigna-rybelsus/"
  },
  {
   "slug": "cigna-wegovy-zepbound",
   "payer": "Cigna / Express Scripts",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg injection and tablet), Zepbound (tirzepatide)",
   "plan_type": "Commercial employer group and individual and family plans",
   "status": "varies-by-plan",
   "answer": "Yes on some plans. Cigna policies IP0814 (Wegovy) and IP0816 (Zepbound), in force since September 1, 2026, cover them for obesity. Your prescriber has to get the plan to sign off first. You need a starting BMI of 30 or more. A BMI of 27 or more also works if you have a weight-related health problem. You also need three months of diet and behavior change. Page one of each policy says your own plan document always supersedes it, so read it first.",
   "employer_election": true,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Obesity / chronic weight management (Wegovy and Zepbound)",
     "status": "covered-with-PA",
     "bmi_threshold": "Baseline BMI 30 or higher. Baseline BMI 27 or higher also qualifies with at least one weight-related condition. The policy lists hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease or non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease. Baseline means your BMI before any GLP-1 or GLP-1/GIP agonist.",
     "step_therapy": "No older weight drug has to fail first. The policy asks for three months of diet and behavior change, and that you keep both going while on the drug.",
     "continuation": "5 percent or more loss of baseline body weight",
     "policy_number": "IP0814 (Wegovy) and IP0816 (Zepbound)",
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Obstructive sleep apnea (Zepbound, SURMOUNT-OSA indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "Baseline BMI 30 or higher",
     "step_therapy": "None. You do not have to fail a breathing machine (PAP) first. You do not need a sleep specialist.",
     "continuation": "After at least 1 year of therapy: 10 percent or more loss of baseline body weight, plus prescriber-reported stability in obstructive sleep apnea signs or symptoms such as snoring, excessive daytime sleepiness or fatigue",
     "policy_number": "IP0816",
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Cardiovascular risk reduction (Wegovy, SELECT indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "Baseline BMI 27 or higher",
     "step_therapy": "None. But your prescriber has to confirm your heart medicines are already optimized for your condition.",
     "continuation": null,
     "policy_number": "IP0814",
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ip_0814_coveragepositioncriteria_weight_loss_wegovy_injection.pdf",
     "title": "Cigna Drug Coverage Policy IP0814, Wegovy Injection, effective September 1, 2026, and IP0816, Zepbound, same date",
     "verified": "2026-11-04"
    },
    {
     "url": "https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ip_0816_coveragepositioncriteria_weight_loss_zepbound.pdf",
     "title": "Cigna Drug Coverage Policy IP0816, Zepbound, effective September 1, 2026",
     "verified": "2026-11-04"
    },
    {
     "url": "https://static.cigna.com/assets/chcp/pdf/coveragePolicies/pharmacy/ip_0814_coveragepositioncriteria_weight_loss_wegovy_injection.pdf",
     "title": "Cigna Drug Coverage Policy IP0814, Wegovy Injection, effective September 1, 2026",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/cigna-wegovy-zepbound/"
  },
  {
   "slug": "fehb-bcbs-wegovy-zepbound",
   "payer": "FEHB Blue Cross Blue Shield (Federal Employee Program)",
   "drug": "Wegovy or Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide)",
   "plan_type": "FEHB FEP Blue Basic, FEP Blue Standard, FEP Blue Focus",
   "status": "covered-with-PA",
   "answer": "Yes. FEHB FEP Blue Cross Blue Shield covers Wegovy and Zepbound with prior authorization. OPM requires every FEHB carrier to cover at least one GLP-1 weight-loss drug.",
   "employer_election": false,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Wegovy for weight management",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher. BMI 27 or higher also works with established cardiovascular disease or at least one weight-related condition: type 2 diabetes, hypertension, or dyslipidemia",
     "step_therapy": null,
     "continuation": null,
     "policy_number": "5.99.030",
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Zepbound for weight management",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher. BMI 27 or higher also works with established cardiovascular disease or at least one weight-related condition: type 2 diabetes, hypertension, or dyslipidemia",
     "step_therapy": "Zepbound has a tighter bar than Wegovy. The file has to show an inadequate response, intolerance or contraindication to at least two oral weight-management drugs (for example phentermine or Qsymia), and the plan's preferred products have to have been tried unless there is a medical exception",
     "continuation": null,
     "policy_number": "5.99.031",
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://www.fepblue.org/-/media/PDFs/Medical-Policies/2026/February/Pharmacy-Policies/Remove-and-Replace/5_99_030-Saxenda-Wegovy.pdf",
     "title": "FEP Blue pharmacy policy 5.99.030, Saxenda and Wegovy, effective February 13, 2026 (PDF)",
     "verified": "2026-11-04"
    },
    {
     "url": "https://www.fepblue.org/-/media/PDFs/Medical-Policies/2026/January/Pharmacy-Policies/Add-New/599031-Zepbound-tirzepatide.pdf",
     "title": "FEP Blue pharmacy policy 5.99.031, Zepbound (tirzepatide), effective January 1, 2026 (PDF)",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/fehb-bcbs-wegovy-zepbound/"
  },
  {
   "slug": "florida-blue-mounjaro",
   "payer": "Florida Blue (Blue Cross and Blue Shield of Florida)",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Florida Blue covers Mounjaro for type 2 diabetes on its commercial plans, once the plan signs off. The prescriber has to write down a type 2 diabetes diagnosis. They also have to show that metformin, a metformin combination drug, or insulin was tried first and failed. Florida Blue does not cover Mounjaro, or any GLP-1, for weight loss. Zepbound is the tirzepatide the FDA approved for weight loss. Florida Blue excludes it from coverage, along with Wegovy and Saxenda.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "119973 0125",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://files.guidewell.com/m/7bf6733fcce9a9ab/original/providers-news-2025-pharmacy-glp-commercial-prior-auth-requirement-01-2025.pdf",
     "title": "GLP-1 Prior Authorization Requirement for Commercial Plans, Effective April 1, 2025",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/florida-blue-mounjaro/"
  },
  {
   "slug": "florida-blue-ozempic",
   "payer": "Florida Blue (Blue Cross and Blue Shield of Florida)",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Florida Blue covers Ozempic for type 2 diabetes on its commercial plans, once the plan signs off. The prescriber has to write down a type 2 diabetes diagnosis. They also have to show that metformin, a metformin combination drug, or insulin was tried first and failed. Ozempic is not covered for weight loss. Wegovy is the semaglutide for weight loss, and Florida Blue excludes it from coverage.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "119973 0125",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://files.guidewell.com/m/7bf6733fcce9a9ab/original/providers-news-2025-pharmacy-glp-commercial-prior-auth-requirement-01-2025.pdf",
     "title": "GLP-1 Prior Authorization Requirement for Commercial Plans, Effective April 1, 2025",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/florida-blue-ozempic/"
  },
  {
   "slug": "florida-blue-rybelsus",
   "payer": "Florida Blue (Blue Cross and Blue Shield of Florida)",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Florida Blue covers Rybelsus for type 2 diabetes on its commercial plans, once the plan signs off. The prescriber has to write down a type 2 diabetes diagnosis. They also have to show that metformin, a metformin combination drug, or insulin was tried first and failed. The FDA approved Rybelsus for type 2 diabetes only. Florida Blue does not cover it, or any GLP-1, for weight loss. Wegovy is the semaglutide for weight loss, and Florida Blue excludes it from coverage.",
   "employer_election": false,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "119973 0125",
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://files.guidewell.com/m/7bf6733fcce9a9ab/original/providers-news-2025-pharmacy-glp-commercial-prior-auth-requirement-01-2025.pdf",
     "title": "GLP-1 Prior Authorization Requirement for Commercial Plans, Effective April 1, 2025",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/florida-blue-rybelsus/"
  },
  {
   "slug": "florida-blue-wegovy-zepbound",
   "payer": "Florida Blue (Blue Cross and Blue Shield of Florida)",
   "drug": "Wegovy and Zepbound for weight loss",
   "drug_full": "Wegovy, Zepbound, Saxenda (obesity, excluded); Mounjaro, Ozempic, Rybelsus, Trulicity (type 2 diabetes, covered with PA)",
   "plan_type": "Commercial fully insured and HMO plans. BlueChoice, BlueOptions, BlueSelect, BlueCare, myBlue, SimplyBlue and Truli for Health",
   "status": "excluded",
   "answer": "No. Florida Blue commercial plans exclude Wegovy, Zepbound and Saxenda for weight loss. They cover GLP-1 drugs only for type 2 diabetes. That comes from Florida Blue's own provider bulletin, in force since April 1, 2025.",
   "employer_election": true,
   "policy_date": "2026-08-18",
   "indications": [
    {
     "label": "Obesity / chronic weight management",
     "status": "excluded",
     "bmi_threshold": "Not applicable. The plan excludes weight-management drugs at any BMI",
     "step_therapy": null,
     "continuation": null,
     "policy_number": "Provider bulletin 119973 0125 (January 2025)",
     "confidence": "high",
     "verified_date": "2026-08-18"
    },
    {
     "label": "Type 2 diabetes (GLP-1 class, covered pathway)",
     "status": "covered-with-PA",
     "bmi_threshold": "Not applicable. BMI plays no part in the diabetes route",
     "step_therapy": "You have to have tried metformin, a metformin combination drug, or insulin, and it has to have failed.",
     "continuation": null,
     "policy_number": "Provider bulletin 119973 0125 (January 2025)",
     "confidence": "high",
     "verified_date": "2026-08-18"
    }
   ],
   "sources": [
    {
     "url": "https://files.guidewell.com/m/7bf6733fcce9a9ab/original/providers-news-2025-pharmacy-glp-commercial-prior-auth-requirement-01-2025.pdf",
     "title": "Florida Blue (GuideWell) provider bulletin, GLP-1 Prior Authorization Requirement for Commercial Plans, effective April 1, 2025",
     "verified": "2026-08-18"
    },
    {
     "url": "https://files.guidewell.com/m/7bf6733fcce9a9ab/original/providers-news-2025-pharmacy-glp-commercial-prior-auth-requirement-01-2025.pdf",
     "title": "Florida Blue (GuideWell) provider bulletin, GLP-1 Prior Authorization Requirement for Commercial Plans, effective April 1, 2025",
     "verified": "2026-08-18"
    }
   ],
   "url": "https://glpchart.com/coverage/florida-blue-wegovy-zepbound/"
  },
  {
   "slug": "highmark-mounjaro",
   "payer": "Highmark Blue Cross Blue Shield",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Highmark covers Mounjaro for type 2 diabetes on its commercial and ACA (Healthcare Reform) plans, under pharmacy policy J-1300. Mounjaro is tirzepatide. The policy names one thing to prove: a type 2 diabetes diagnosis on the record, ICD-10 E11. A member with a claim for another diabetes drug in the past 720 days is approved at the pharmacy counter, with no sign-off at all. Highmark does not cover Mounjaro for weight loss, and will not approve it for obesity on its own. Zepbound is the tirzepatide the FDA approved for weight loss, and it sits under a separate Highmark weight-loss policy.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "J-1300",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://securecms.highmark.com/content/dam/pharmacypolicy/en/highmark/all/policy/J1201-1300/1300/J-1300-002.pdf",
     "title": "Pharmacy Policy Bulletin J-1300: Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) for Diabetes - Commercial and Healthcare Reform",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/highmark-mounjaro/"
  },
  {
   "slug": "highmark-ozempic",
   "payer": "Highmark Blue Cross Blue Shield",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Highmark covers Ozempic for type 2 diabetes on its commercial drug lists. It usually sits at Tier 2, the plan has to sign off, and a quantity limit applies. Ozempic is not covered for weight loss, because the FDA approved it for type 2 diabetes only. Wegovy is the semaglutide Highmark covers for weight loss. That one runs under a separate weight-loss drug policy, and a self-insured employer can turn it down.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "medium",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://client.formularynavigator.com/Search.aspx?siteCode=8103967260",
     "title": "Highmark Comprehensive Formulary (commercial drug list search)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/highmark-ozempic/"
  },
  {
   "slug": "highmark-rybelsus",
   "payer": "Highmark Blue Cross Blue Shield",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Highmark covers Rybelsus for type 2 diabetes under pharmacy policy J-1300. The sign-off clears on its own at the pharmacy counter for a member with two things on file. One is a type 2 diabetes diagnosis, ICD-10 E11. The other is a pharmacy claim in the past 720 days for another diabetes drug that is not a GLP-1. A member without that recent history needs a standard sign-off. Rybelsus is not covered for weight loss. The FDA approved it for type 2 diabetes only, and Highmark will not approve it for obesity on its own. Wegovy is the semaglutide for weight loss, and Highmark reviews it under a separate weight-loss policy.",
   "employer_election": false,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "J-1300",
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://securecms.highmark.com/content/dam/pharmacypolicy/en/highmark/all/policy/J1201-1300/1300/J-1300-002.pdf",
     "title": "Pharmacy Policy Bulletin: J-1300 Glucagon-Like Peptide-1 Receptor Agonists (GLP-1 RAs) for Diabetes - Commercial and Healthcare Reform",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/highmark-rybelsus/"
  },
  {
   "slug": "highmark-wegovy-zepbound",
   "payer": "Highmark Blue Cross Blue Shield",
   "drug": "Zepbound and Wegovy for weight loss",
   "drug_full": "Zepbound, Wegovy, Saxenda, Foundayo (obesity); Zepbound (OSA)",
   "plan_type": "Commercial fully insured and ACA",
   "status": "covered-with-PA",
   "answer": "Yes, once the plan signs off. Highmark's commercial and ACA plans cover Zepbound and Wegovy for weight management under policy J-1388. Zepbound is the one the plan prefers. Highmark's own rule is tighter than the drug label. It requires a starting BMI of 40 or higher, plus a qualifying weight-related condition. The label sets the bar at BMI 30. A self-funded employer can still carve the benefit out, so check that your plan has it before you submit.",
   "employer_election": true,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Obesity / chronic weight management",
     "status": "covered-with-PA",
     "bmi_threshold": "A starting BMI of 40 or higher, plus a qualifying weight-related condition. This is Highmark's own rule. It is tighter than the drug label, which sets the bar at BMI 30, or 27 with a weight-related condition",
     "step_therapy": "Six months of diet and physical activity on the record before you start, kept up while you are on the drug. Zepbound is the drug the plan prefers. So a request for Wegovy, Saxenda or Foundayo has to show that Zepbound is not safe for you, or that you could not tolerate it.",
     "continuation": null,
     "policy_number": "J-1388",
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Obstructive sleep apnea (SURMOUNT-OSA indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher. This is the sleep-apnea route on its own, and it runs only on Delaware plans with no obesity benefit",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://securecms.highmark.com/content/dam/pharmacypolicy/en/highmark/all/policy/J1301-1400/1388/J-1388-028.pdf",
     "title": "Highmark Pharmacy Policy J-1388 Anti-Obesity (Enhanced), Commercial and Healthcare Reform",
     "verified": "2026-11-04"
    },
    {
     "url": "https://securecms.highmark.com/content/dam/pharmacypolicy/en/highmark/all/policy/J1301-1400/1388/J-1388-028.pdf",
     "title": "Highmark Pharmacy Policy J-1388 Anti-Obesity (Enhanced), Commercial and Healthcare Reform",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/highmark-wegovy-zepbound/"
  },
  {
   "slug": "humana-mounjaro",
   "payer": "Humana",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Medicare Part D",
   "status": "varies-by-plan",
   "answer": "Humana lists Mounjaro as a covered brand drug for type 2 diabetes on its 2026 Medicare Part D drug lists. Mounjaro is tirzepatide. On the Humana Value Rx Plan and the Humana Premier Rx Plan it sits at tier 3, the plan has to sign off, and a quantity limit of 2 pens per 28 days applies. The FDA approved Mounjaro for type 2 diabetes only. Part D does not cover drugs used only for weight loss, so it will not pay for Mounjaro prescribed to lose weight. Zepbound is the weight-loss form of the same tirzepatide, and Part D does not cover that either.",
   "employer_election": false,
   "policy_date": "2026-09-07",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "Formulary 26400 (Y0040_PDG26_FINAL_3C_C)",
     "confidence": "high",
     "verified_date": "2026-09-07"
    }
   ],
   "sources": [
    {
     "url": "https://assets.humana.com/is/content/humana/20260003PDG2640026Cpdf",
     "title": "Humana 2026 Prescription Drug Guide, Humana Value Rx Plan (PDP), Formulary 26400 (updated 09/02/2026)",
     "verified": "2026-09-07"
    }
   ],
   "url": "https://glpchart.com/coverage/humana-mounjaro/"
  },
  {
   "slug": "humana-ozempic",
   "payer": "Humana",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Medicare Part D",
   "status": "covered-with-PA",
   "answer": "Humana's 2026 Medicare Part D drug lists cover Ozempic for type 2 diabetes, its only FDA-approved use. The plan has to sign off, and a quantity limit of 3 pens per 28 days applies. Ozempic sits at tier 3 on the Premier Rx, Value Rx and HumanaChoice 2026 lists, and none of them makes you try another drug first. Part D does not cover drugs used only for weight loss, and Ozempic has no weight-loss approval. Wegovy is the same semaglutide at a higher dose, approved for weight loss.",
   "employer_election": false,
   "policy_date": "2026-09-07",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "Y0040_PDG26_FINAL_5C_C",
     "confidence": "high",
     "verified_date": "2026-09-07"
    }
   ],
   "sources": [
    {
     "url": "https://assets.humana.com/is/content/humana/20260005PDG2640226Cpdf",
     "title": "Humana 2026 Prescription Drug Guide, Humana Premier Rx Plan (PDP), Formulary 26402 (updated 09/02/2026)",
     "verified": "2026-09-07"
    }
   ],
   "url": "https://glpchart.com/coverage/humana-ozempic/"
  },
  {
   "slug": "humana-rybelsus",
   "payer": "Humana",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Medicare Part D",
   "status": "varies-by-plan",
   "answer": "Some of Humana's 2026 Medicare Part D drug lists cover Rybelsus for type 2 diabetes. The tier and the rules differ by plan. On the HumanaChoice (PPO) 2026 list Rybelsus sits at tier 3, the plan has to sign off, and a quantity limit of 30 tablets per 30 days applies. The Premier Rx and Value Rx standalone Part D lists do not carry it. Rybelsus has no weight-loss approval, so Part D will not cover it for weight loss. Wegovy is the semaglutide approved for weight loss.",
   "employer_election": false,
   "policy_date": "2026-09-07",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "Y0040_PDG26_FINAL_15C_C",
     "confidence": "high",
     "verified_date": "2026-09-07"
    }
   ],
   "sources": [
    {
     "url": "https://assets.humana.com/is/content/humana/20260015PDG2640826Cpdf",
     "title": "Humana 2026 Prescription Drug Guide, HumanaChoice (PPO), Formulary 26408 (updated 09/02/2026)",
     "verified": "2026-09-07"
    }
   ],
   "url": "https://glpchart.com/coverage/humana-rybelsus/"
  },
  {
   "slug": "humana-wegovy-zepbound",
   "payer": "Humana",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide)",
   "plan_type": "Medicare Advantage plans with drug coverage, and Humana standalone Medicare Part D plans",
   "status": "split",
   "answer": "No on Humana's Medicare drug lists. The 2026 HumanaChoice, Premier Rx and Value Rx drug guides do not list either drug. Humana's Medicare page says standard Part D plans do not cover GLP-1 drugs used only for weight loss, and that Part D can cover Ozempic or Wegovy when the prescription is for diabetes or cardiovascular disease. The one covered weight-loss route is the Medicare GLP-1 Bridge, a CMS program that runs to December 31, 2027.",
   "employer_election": false,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Obesity / weight loss only, standard Part D",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Wegovy and Zepbound on Humana's 2026 Medicare drug lists",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "Y0040_PDG26_FINAL_15C_C",
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Obesity / weight loss through the Medicare GLP-1 Bridge",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://www.humana.com/medicare/medicare-resources/does-medicare-cover-weight-loss-drugs",
     "title": "Humana, Does Medicare cover GLP-1 weight loss drugs? (updated 06/08/2026) (page updated June 8, 2026)",
     "verified": "2026-11-04"
    },
    {
     "url": "https://assets.humana.com/is/content/humana/20260015PDG2640826Cpdf",
     "title": "Humana 2026 Prescription Drug Guide, HumanaChoice (PPO), Formulary 26408 (updated 09/02/2026)",
     "verified": "2026-11-04"
    },
    {
     "url": "https://www.humana.com/medicare/medicare-resources/does-medicare-cover-weight-loss-drugs",
     "title": "Humana, Does Medicare cover GLP-1 weight loss drugs? (updated 06/08/2026)",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/humana-wegovy-zepbound/"
  },
  {
   "slug": "independence-blue-cross-glp1",
   "payer": "Independence Blue Cross",
   "drug": "GLP-1 medications",
   "drug_full": "Wegovy, Zepbound, Ozempic, Mounjaro",
   "plan_type": "Commercial fully insured plans, individual and group",
   "status": "split",
   "answer": "No on standard plans. Independence Blue Cross covers Wegovy and Zepbound for weight loss only on plans that bought its weight-loss rider. GLP-1s stay covered for type 2 diabetes and cardiovascular disease. Both routes need prior approval.",
   "employer_election": false,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Weight loss only, standard plans",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Weight loss, on a plan that bought the rider",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Type 2 diabetes and cardiovascular disease",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://provcomm.ibx.com/pnc-ibc/news/Pages/Changes-coming-to-weight-loss-drug-coverage-benefits.aspx",
     "title": "Independence Blue Cross, Changes coming to weight loss drug coverage benefits, effective January 1, 2025",
     "verified": "2026-11-04"
    },
    {
     "url": "https://www.ibx.com/pdfs/resources/for-providers/formularies/select-drug-guide.pdf",
     "title": "Independence Blue Cross Select Drug Program Formulary, effective October 1, 2026",
     "verified": "2026-11-04"
    },
    {
     "url": "https://provcomm.ibx.com/pnc-ibc/news/Pages/Changes-coming-to-weight-loss-drug-coverage-benefits.aspx",
     "title": "Independence Blue Cross, Changes coming to weight loss drug coverage benefits, effective January 1, 2025",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/independence-blue-cross-glp1/"
  },
  {
   "slug": "kaiser-mounjaro",
   "payer": "Kaiser Permanente",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Kaiser Permanente covers Mounjaro for type 2 diabetes, but the plan has to sign off, and the step therapy runs long. The Northwest criteria Kaiser publishes require you to be on semaglutide at the maximum tolerated dose, 2 mg once a week, for at least 3 months, or to have failed it. They also require metformin, a sulfonylurea, pioglitazone and an SGLT2 inhibitor, with the A1C still above 6.9%. The FDA approved Mounjaro for type 2 diabetes only, so Kaiser does not cover it for weight loss. Zepbound is the weight-loss tirzepatide, and Kaiser covers that one only where the employer plan buys a weight-loss drug benefit.",
   "employer_election": true,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-mounjaro-nw-en.pdf",
     "title": "Kaiser Permanente Northwest Region, Criteria for Drug Coverage: tirzepatide (Mounjaro)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/kaiser-mounjaro/"
  },
  {
   "slug": "kaiser-ozempic",
   "payer": "Kaiser Permanente",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Kaiser Permanente covers Ozempic for type 2 diabetes, but the plan has to sign off first. It runs that sign-off through its own Criteria-Based Consultation Prescribing Program. Approval needs a documented type 2 diabetes diagnosis, and it needs step therapy. That is usually a trial of metformin plus other diabetes drugs, with the A1C still above target. Kaiser does not cover Ozempic for weight loss under the standard drug benefit. Wegovy is the same semaglutide at a higher dose, and it is the version the FDA approved for weight loss. The criteria here are the ones Kaiser Permanente Northwest publishes. Each region sets its own criteria and its own drug list, so the details can differ across Kaiser's California, Colorado, Mid-Atlantic, Georgia, Hawaii and Washington plans.",
   "employer_election": true,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-criteria-ozempic-injection-nw-en-commercial.pdf",
     "title": "Injectable semaglutide (Ozempic): Criteria for Drug Coverage, Kaiser Permanente Northwest Region",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/kaiser-ozempic/"
  },
  {
   "slug": "kaiser-permanente-glp1",
   "payer": "Kaiser Permanente",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide)",
   "plan_type": "Commercial HMO, marketplace and small or large group plans across the Kaiser regional health plans",
   "status": "varies-by-plan",
   "answer": "Yes on some plans, and the region you are in decides it. Kaiser Permanente is a set of regional health plans, each one licensed on its own. Each sets its own drug list and its own rules. Wegovy sits at Tier 2 on both 2026 California commercial drug lists. It sits at Tier 5 on the Georgia list, and the plan has to sign off there. It became formulary in the Northwest on June 18, 2026. It is not on the Colorado, Hawaii or Washington commercial lists at all. Zepbound is on the Georgia and Washington lists, and non-formulary in the Northwest. On top of that split, the Northwest rules cover you only if your plan carries the weight-loss drug benefit.",
   "employer_election": true,
   "policy_date": "2026-08-15",
   "indications": [
    {
     "label": "Obesity / chronic weight management (Kaiser Permanente Northwest)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher. BMI 27 or higher also works with at least one documented condition from a list of 11: hypertension, type 2 diabetes, hyperlipidemia, pre-diabetes, established cardiovascular disease or stroke, congestive heart failure, chronic kidney disease, non-alcoholic fatty liver disease, obstructive sleep apnea, osteoarthritis in weight-bearing joints, or polycystic ovarian syndrome. A patient aged 12 to 17 qualifies at BMI 35 or higher, with one qualifying weight-related condition.",
     "step_therapy": "A failed 3-month trial of at least two of these: phentermine, diethylpropion, topiramate, Qsymia or Contrave. An allergy, an intolerance, or a contraindication to all of them counts instead. Zepbound carries a second step on top. You need a failed trial of semaglutide (Ozempic or Wegovy) of at least 6 months. A bariatric medicine chart review then decides whether the switch is necessary. A documented allergy, intolerance or contraindication to semaglutide counts instead.",
     "continuation": "Updated weight and BMI documented, and 5 percent or greater weight loss achieved and maintained since starting the drug",
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obstructive sleep apnea (Kaiser Permanente Northwest)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": "The oral-drug step is the same one the weight-management route uses. A failed 3-month trial of at least two of these: phentermine, diethylpropion, topiramate, Qsymia or Contrave. An allergy, an intolerance, or a contraindication to all of them counts instead. The Northwest criteria do not require documented PAP therapy first.",
     "continuation": "Updated weight and BMI documented, and 5 percent or greater weight loss achieved and maintained since starting the drug",
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obesity / chronic weight management (Kaiser Permanente Mid-Atlantic States)",
     "status": "covered-with-PA",
     "bmi_threshold": "Baseline BMI 30 or higher, or 27 to under 30 with at least one weight-related condition: established cardiovascular disease or stroke, hypertension, type 2 diabetes, chronic kidney disease, coronary heart disease, polycystic ovarian syndrome, dyslipidemia, non-alcoholic fatty liver disease, idiopathic intracranial hypertension, or osteoarthritis in weight-bearing joints",
     "step_therapy": "You need a 3-month trial of all of phentermine, Qsymia and Contrave. The file has to document an intolerance, a contraindication, or a failure to lose and keep off 5 percent or more of body weight. Saxenda and Zepbound add a fourth step. That is a 3-month trial of Wegovy, at the highest dose you can tolerate. A Zepbound request also needs at least 16 weeks off every GLP-1 and GIP/GLP-1 drug first, spent on lifestyle change.",
     "continuation": "Documented weight loss of at least 5 percent from baseline within the previous 3 months",
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obstructive sleep apnea (Zepbound, Kaiser Permanente Mid-Atlantic States)",
     "status": "covered-with-PA",
     "bmi_threshold": "Baseline BMI 35 or higher",
     "step_therapy": "PAP therapy used for at least 3 months and continuing, or documentation that the patient cannot use PAP. On top of that, the same 3-month trial of phentermine, Qsymia and Contrave, plus a 3-month trial of Wegovy at the maximum tolerated dose.",
     "continuation": "Continues to meet the initial criteria apart from the baseline BMI requirement, and none of the listed reasons for non-coverage apply",
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obesity / chronic weight management (Kaiser Permanente California)",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obesity / chronic weight management (Kaiser Permanente Georgia)",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Weight-loss drugs (Kaiser Permanente Colorado)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Weight-loss drugs (Kaiser Foundation Health Plan of Washington)",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Weight-loss drugs (Kaiser Permanente Hawaii)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Anti-obesity medications (Kaiser Permanente FEHB plans)",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    }
   ],
   "sources": [
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-criteria-wegovy-injection-nw-en-commercial.pdf",
     "title": "Kaiser Permanente Northwest Region Criteria for Drug Coverage, semaglutide injectable (Wegovy, Wegovy HD), Criteria-Based Consultation Prescribing Program, revised June 11 2026, effective June 18 2026",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-criteria-zepbound-nw-en-commercial.pdf",
     "title": "Kaiser Permanente Northwest Region Criteria for Drug Coverage, tirzepatide (Zepbound), Criteria-Based Consultation Prescribing Program, revised June 11 2026, effective June 18 2026",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/community-providers/mas/2024/hmo-exchange-prior-authorization-pa-form-for-weight-management-agents-wegovy-and-saxenda-en.pdf",
     "title": "Kaiser Permanente Health Plan of Mid-Atlantic States, Weight Management Agents (Wegovy, Saxenda, & Zepbound) Prior Authorization form, revision date September 22 2025, effective October 7 2025",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/community-providers/mas/2024/hmo-exchange-prior-authorization-pa-form-for-weight-management-agents-wegovy-and-saxenda-en.pdf",
     "title": "Kaiser Permanente Health Plan of Mid-Atlantic States, Weight Management Agents (Wegovy, Saxenda, & Zepbound) Prior Authorization form, revision date September 22 2025, effective October 7 2025, moderate-to-severe OSA section",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/ca/commercial-marketplace-formulary-ca-en-2026-drug-formulary.pdf",
     "title": "Kaiser Permanente 2026 California Commercial Marketplace Formulary, updated August 1 2026, effective August 4 2026, semaglutide (weight management) entries on page 93 and the formulary abbreviation key on page 10",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/ga/five-tier-formulary-benefit-ga-en-2026-drug-formulary.pdf",
     "title": "Kaiser Permanente of Georgia 2026 Five-Tier Formulary Benefit, current as of July 8 2026, Wegovy Zepbound and Saxenda entries plus the tier key",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/co/hmo-formulary-co-en-2026.pdf",
     "title": "Kaiser Permanente Colorado Commercial Formulary (List of Covered Drugs), revision date July 21 2026, weight reduction section and the non-formulary drug rule",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/wa/if-sg-drug-formulary-wa-en.pdf",
     "title": "Kaiser Permanente Washington 2026 Drug Formulary for individual and family plans and small employer groups, effective August 1 2026, Zepbound entries and the plan exclusions paragraph",
     "verified": "2026-08-15"
    },
    {
     "url": "https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/health-plan-documents/eoc/hi/individual-family/2026/on-silver-4000-600-ai-ltd-hi-en.pdf",
     "title": "Kaiser Foundation Health Plan Inc Hawaii, 2026 Guide to Your Health Plan and Evidence of Coverage (Silver 4000 individual and family), prescription drug Services Not Covered and the Weight Program Management exclusion",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/pdf/2026/brochures/73-004.pdf",
     "title": "2026 Kaiser Permanente Northwest FEHB plan brochure RI 73-004, Section 5(f) prescription drug benefits and the 2026 changes summary",
     "verified": "2026-08-15"
    }
   ],
   "url": "https://glpchart.com/coverage/kaiser-permanente-glp1/"
  },
  {
   "slug": "medicare-wegovy-zepbound",
   "payer": "Medicare Part D",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy, Zepbound, Saxenda",
   "plan_type": "Medicare Part D, all plans including Humana, Wellcare, Cigna, Aetna, and UnitedHealthcare Medicare",
   "status": "split",
   "answer": "No for weight loss alone. A 2003 federal statute bars Medicare Part D from covering any GLP-1 prescribed only for weight loss. It does cover Wegovy for cardiovascular risk reduction and Zepbound for moderate-to-severe sleep apnea, because those are non-obesity indications.",
   "employer_election": false,
   "policy_date": "2026-06-12",
   "indications": [
    {
     "label": "Obesity / weight loss only",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Wegovy for cardiovascular risk reduction (SELECT indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 27 or higher with established cardiovascular disease",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Zepbound for obstructive sleep apnea (SURMOUNT-OSA indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    }
   ],
   "sources": [
    {
     "url": "https://www.wellcare.com/en/resources/does-medicare-cover-weight-loss-drugs",
     "title": "Wellcare, Does Medicare Cover Weight-Loss Drugs? (confirms the Part D statutory exclusion for weight loss)",
     "verified": "2026-06-12"
    },
    {
     "url": "https://www.wellcare.com/en/resources/does-medicare-cover-weight-loss-drugs",
     "title": "Wellcare, Does Medicare Cover Weight-Loss Drugs? Understanding GLP-1 Coverage in 2026",
     "verified": "2026-06-12"
    },
    {
     "url": "https://www.wellcare.com/en/resources/does-medicare-cover-weight-loss-drugs",
     "title": "Wellcare, Does Medicare Cover Weight-Loss Drugs? Understanding GLP-1 Coverage in 2026",
     "verified": "2026-06-12"
    }
   ],
   "url": null
  },
  {
   "slug": "molina-mounjaro",
   "payer": "Molina Healthcare",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "varies-by-plan",
   "answer": "Molina covers Mounjaro for type 2 diabetes, the use the FDA approved. The plan has to sign off, and quantity limits apply. Molina runs a separate Marketplace drug list and a separate Medicaid drug list in each state. So the tier, any step-therapy rule, and the exact limits differ by plan and by location. Mounjaro is not covered for weight loss. That use belongs to Zepbound, which Molina lists in a separate anti-obesity section and restricts. Check the drug list for your own state plan before you count on coverage.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "medium",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://fm.formularynavigator.com/FBO/247/Medicaid_PDL_Formulary_MI.pdf",
     "title": "Molina Healthcare of Michigan Preferred Drug List (Formulary), August 2026 to October 2026",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/molina-mounjaro/"
  },
  {
   "slug": "molina-ozempic",
   "payer": "Molina Healthcare",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Yes. On Molina's ACA Marketplace plans, Ozempic is covered for type 2 diabetes. Ozempic is semaglutide, and it is listed under GLP-1 receptor agonists on the drug list. Molina publishes a separate drug list in each state, so the tier and the cost share can differ. On the 2026 Texas and Washington lists we checked, it sits at tier 3, with step therapy and a quantity limit. So a member generally has to try a preferred diabetes drug first. The FDA approved Ozempic for type 2 diabetes only, and Molina does not cover it for weight loss. The weight-loss semaglutide is Wegovy. Neither Wegovy nor the other weight-loss GLP-1s are on the Marketplace drug list.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.molinahealthcare.com/marketplace/tx/en-us/-/media/Molina/PublicWebsite/PDF/members/tx/en-us/Marketplace/2026/TXFormulary2026.pdf",
     "title": "Molina Healthcare of Texas Marketplace 2026 Formulary (List of Covered Drugs), current as of July 1, 2026",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/molina-ozempic/"
  },
  {
   "slug": "molina-wegovy-zepbound",
   "payer": "Molina Healthcare",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide), Wegovy HD, Wegovy tablets, Zepbound (tirzepatide)",
   "plan_type": "ACA Marketplace individual and family plans sold as Molina Marketplace",
   "status": "varies-by-plan",
   "answer": "Not on a Molina marketplace plan in a state whose member agreement lists weight loss drugs as non-covered. Molina writes a criteria document for Wegovy and one for Zepbound, and neither of them holds a single clinical rule. Every field that would carry a BMI number, an age limit, a step therapy rule or an approval length reads N/A. In their place sits one sentence, calling the drug a benefit exclusion for all indications. That sentence names three uses inside the exclusion: to lower cardiovascular risk, to treat liver disease, and to treat sleep apnea. Both documents make the answer depend on the state. So we read four 2026 member agreements. Texas and Florida list weight loss drugs under Non-Covered Drugs, with no exception attached. California and New Mexico are the exceptions, and each one is written into that state's own member agreement.",
   "employer_election": false,
   "policy_date": "2026-08-15",
   "indications": [
    {
     "label": "Obesity / chronic weight management (Wegovy)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "C27682-A",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Cardiovascular risk reduction and liver disease (Wegovy)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "C27682-A",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obesity and obstructive sleep apnea (Zepbound)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "C29112-A",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "What the member agreement says (Texas and Florida)",
     "status": "excluded",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Morbid obesity, Class III (California marketplace only)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 40 or higher. BMI 35 or higher also works for a member with an obesity-related health condition. The policy gives its own examples: diabetes, impaired glucose tolerance, dyslipidemia, hypertension, coronary heart disease or sleep apnea",
     "step_therapy": "For members with type 2 diabetes, a documented trial of all formulary GLP-1 or GLP-1/GIP agents indicated for diabetes, with an inadequate response to each. The policy defines an inadequate response as two failures together. The member failed to reach the expected A1c lowering goal while sticking with the drug. The member also failed to reach their own individualized therapy goals.",
     "continuation": "At least 10 percent of baseline body weight lost, or kept off. The prescriber also has to confirm the member is sticking with a formalized weight management program. An authorization past 12 months of continuous Saxenda or Wegovy therapy needs documented weight maintenance and continued program participation. The policy sets a hard stop too. If the member has not lost at least 10 percent of baseline body weight by week 24, the drug must be stopped.",
     "policy_number": "C28425-A",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obesity and morbid obesity (New Mexico marketplace only)",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": "Not published. Molina's Wegovy and Zepbound criteria documents send a New Mexico request off to a policy of its own. It is called Weight Management Therapy NM MMKP C29220-A. Molina does not publish it on the New Mexico provider drug criteria index.",
     "policy_number": null,
     "confidence": "medium",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Formulary placement across the 2026 Molina marketplace drug lists",
     "status": "varies-by-plan",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-15"
    }
   ],
   "sources": [
    {
     "url": "https://www.molinamarketplace.com/marketplace/sc/en-us/Providers/-/media/D84835628C9549BFB30D1D6F9EDBAC8E.ashx",
     "title": "Molina Healthcare Drug and Biologic Coverage Criteria, Wegovy (semaglutide) NC, Policy Number C27682-A, Current Effective Date 05/30/2026, Required Medical Information section",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.molinamarketplace.com/marketplace/sc/en-us/Providers/-/media/D84835628C9549BFB30D1D6F9EDBAC8E.ashx",
     "title": "Molina Healthcare Drug and Biologic Coverage Criteria, Wegovy (semaglutide) NC, Policy Number C27682-A, Diagnosis, Required Medical Information and FDA-Approved Uses sections",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.molinamarketplace.com/marketplace/sc/en-us/Providers/-/media/ED2C6F09F1D84EF1A25C2592FCA62739.ashx",
     "title": "Molina Healthcare Drug and Biologic Coverage Criteria, Zepbound (tirzepatide) NC, Policy Number C29112-A, Current Effective Date 12/11/2025, Required Medical Information and Background sections",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.molinamarketplace.com/marketplace/tx/en-us/-/media/Molina/PublicWebsite/PDF/members/tx/en-us/Marketplace/2026/TX26EOCE_SM.ashx",
     "title": "Molina Healthcare of Texas Off-Exchange 2026 Agreement and Evidence of Coverage, document TX26EOCE_SM, Non-Covered Drugs section",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.molinamarketplace.com/marketplace/ca/en-us/Providers/-/media/282BBCE2827D4681AE5A616E61C5825F.ashx",
     "title": "Molina Healthcare Drug and Biologic Coverage Criteria, Medical Necessity for Morbid obesity (Class III Obesity) CA MKP ONLY, Policy Number C28425-A, Required Medical Information and Continuation of Therapy sections",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.molinahealthcare.com/marketplace/nm/en-us/-/media/Molina/PublicWebsite/PDF/members/nm/en-us/Marketplace/2026/NMFormulary2026.pdf",
     "title": "Molina Marketplace New Mexico 2026 Formulary, Anorexiants Non-Amphetamine and Anti-Obesity GIP and GLP-1 Receptor Agonists sections",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.molinahealthcare.com/marketplace/tx/en-us/-/media/Molina/PublicWebsite/PDF/members/tx/en-us/Marketplace/2026/TXFormulary2026.pdf",
     "title": "Molina Marketplace Texas 2026 Formulary, 161 pages, formulary introduction and the ADHD/Anti-Narcolepsy/Anti-Obesity/Anorexiants section",
     "verified": "2026-08-15"
    }
   ],
   "url": "https://glpchart.com/coverage/molina-wegovy-zepbound/"
  },
  {
   "slug": "oscar-mounjaro",
   "payer": "Oscar Health",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Oscar does cover Mounjaro for type 2 diabetes, once the plan signs off. It sits on tier 2 of Oscar's 2026 drug list, with a quantity limit of four pens every 28 days. Approval needs a documented type 2 diabetes diagnosis, for example an A1C of 6.5% or higher. On top of that you need either a 90-day trial of metformin at 1,500 mg a day that failed, or a documented need for combination therapy with an A1C of 7.5% or higher. Oscar does not cover Mounjaro for weight loss, because the FDA approved it for type 2 diabetes only. Zepbound is the tirzepatide for weight loss. Oscar reviews that one under a separate weight-loss policy, and it is not on this 2026 drug list.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "PG152 (Ver. 4)",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://assets.ctfassets.net/plyq12u1bv8a/5YTLqryOqF4fCoAtHfAZRS/ec01ed54ca59b0b70ac14aa5a97bf7b7/PG152_Antidiabetic_Agents_-_Glucagon-like_Peptide-1__GLP-1__Receptor_Agonists_v4.pdf",
     "title": "Oscar Clinical Guideline: Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 4)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/oscar-mounjaro/"
  },
  {
   "slug": "oscar-ozempic",
   "payer": "Oscar Health",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Oscar covers Ozempic for type 2 diabetes, once the plan signs off. A quantity limit of one pen per fill period applies. It sits on tier 2 of Oscar's 2026 standard drug list. Ozempic is not covered for weight loss. Wegovy is the semaglutide the FDA approved for weight loss, and Oscar's standard individual plans usually leave weight-loss GLP-1 drugs out.",
   "employer_election": false,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "PG152 v9",
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://assets.ctfassets.net/plyq12u1bv8a/4XMDEddZ1G6MuF72UnfOKm/0b302935fec02e8b1182ce9b4d6771cc/Oscar_6T_TN_STND_Member_Doc__January_2026__as_of_09162025.pdf",
     "title": "Oscar 2026 Formulary: List of Covered Drugs (six-tier Tennessee standard plans, file dated as of September 16, 2025): Ozempic tier 2, PA, 1 pen every 28 days (2 mg and 4 mg pens) or every 30 days (8 mg pen)",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/oscar-ozempic/"
  },
  {
   "slug": "oscar-rybelsus",
   "payer": "Oscar Health",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Oscar covers Rybelsus for type 2 diabetes, once the plan signs off. A quantity limit of 30 tablets every 30 days applies. It sits on tier 2 of Oscar's 2026 standard drug list. The FDA approved Rybelsus for type 2 diabetes only, not for weight loss. Wegovy is the semaglutide the FDA approved for weight loss, and Oscar's standard individual plans usually leave weight-loss GLP-1 drugs out.",
   "employer_election": false,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "PG152 v9",
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://assets.ctfassets.net/plyq12u1bv8a/4XMDEddZ1G6MuF72UnfOKm/0b302935fec02e8b1182ce9b4d6771cc/Oscar_6T_TN_STND_Member_Doc__January_2026__as_of_09162025.pdf",
     "title": "Oscar 2026 Formulary: List of Covered Drugs",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/oscar-rybelsus/"
  },
  {
   "slug": "oscar-wegovy-zepbound",
   "payer": "Oscar Health",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (CV and MASH), Zepbound (OSA)",
   "plan_type": "Commercial and ACA marketplace",
   "status": "split",
   "answer": "No for weight loss alone. Oscar Health covers Wegovy for cardiovascular risk and MASH, and Zepbound for sleep apnea, all with prior authorization.",
   "employer_election": false,
   "policy_date": "2026-06-12",
   "indications": [
    {
     "label": "Wegovy for cardiovascular risk reduction (SELECT) and MASH",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Zepbound for obstructive sleep apnea (SURMOUNT-OSA indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    }
   ],
   "sources": [
    {
     "url": "https://www.hioscar.com/clinical-guidelines/pharmacy",
     "title": "Oscar Health, Clinical Guidelines: Pharmacy",
     "verified": "2026-06-12"
    },
    {
     "url": "https://www.hioscar.com/clinical-guidelines/pharmacy",
     "title": "Oscar Health, Clinical Guidelines: Pharmacy",
     "verified": "2026-06-12"
    }
   ],
   "url": null
  },
  {
   "slug": "premera-mounjaro",
   "payer": "Premera Blue Cross",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Premera covers Mounjaro for type 2 diabetes once the plan signs off. Pharmacy policy 5.01.569, in force from July 1, 2026, sets the rules. It calls Mounjaro medically necessary for adults, and for children aged 10 or older, who have a type 2 diabetes diagnosis. They also need an adequate trial of metformin, or a contraindication to it. It cannot be taken with another GLP-1 or GIP/GLP-1 drug. Premera does not cover Mounjaro for weight loss, and it calls that use investigational. Zepbound is the tirzepatide for weight loss, and it runs under a separate policy, 5.01.621.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "5.01.569",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.premera.com/medicalpolicies/5.01.569.pdf",
     "title": "Pharmacotherapy of Type 1 and Type 2 Diabetes Mellitus (Policy 5.01.569)",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/premera-mounjaro/"
  },
  {
   "slug": "premera-ozempic",
   "payer": "Premera Blue Cross",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Premera Blue Cross covers Ozempic for type 2 diabetes once the plan signs off. You have to be 18 or older, with a type 2 diabetes diagnosis. You also need an adequate trial of metformin, or a contraindication to it. A quantity limit holds you to the FDA-approved maximum daily dose. Premera does not cover Ozempic for weight loss, and it calls that use investigational. The weight-loss form of semaglutide is Wegovy. Premera reviews Wegovy under a separate weight-management policy, and that one only applies where the employer group bought weight-loss drug coverage.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "5.01.569",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.premera.com/medicalpolicies/5.01.569.pdf",
     "title": "Pharmacotherapy of Type 1 and Type 2 Diabetes Mellitus",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/premera-ozempic/"
  },
  {
   "slug": "premera-rybelsus",
   "payer": "Premera Blue Cross",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "Premera Blue Cross covers Rybelsus for type 2 diabetes once the plan signs off. Pharmacy policy 5.01.569, in force from July 1, 2026, sets the rules. It treats Rybelsus as a first-line GLP-1. It calls the drug medically necessary for adults aged 18 or older who have a type 2 diabetes diagnosis. They also need an adequate trial of metformin, or a contraindication to it. It cannot be taken with another GLP-1 or GIP/GLP-1 drug. The FDA approved Rybelsus for type 2 diabetes only, so Premera does not cover it for weight loss. Wegovy is the semaglutide for weight loss. Premera reviews Wegovy under a separate policy, 5.01.621, and that one only applies where the employer group bought weight-management drug coverage.",
   "employer_election": false,
   "policy_date": "2026-08-28",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": true,
     "continuation": null,
     "policy_number": "5.01.569",
     "confidence": "high",
     "verified_date": "2026-08-28"
    }
   ],
   "sources": [
    {
     "url": "https://www.premera.com/medicalpolicies/5.01.569.pdf",
     "title": "Pharmacotherapy of Type 1 and Type 2 Diabetes Mellitus",
     "verified": "2026-08-28"
    }
   ],
   "url": "https://glpchart.com/coverage/premera-rybelsus/"
  },
  {
   "slug": "premera-wegovy",
   "payer": "Premera Blue Cross",
   "drug": "Wegovy",
   "drug_full": "Wegovy (semaglutide 2.4 mg)",
   "plan_type": "Commercial plans and Medicare Advantage",
   "status": "varies-by-plan",
   "answer": "Yes on some plans. Premera covers Wegovy once the plan signs off. But it only covers it where your employer bought the weight-loss drug benefit.",
   "employer_election": true,
   "policy_date": "2026-06-12",
   "indications": [
    {
     "label": "Obesity / chronic weight management",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher. BMI 27 or higher also qualifies with a comorbidity, per the criteria in policy 5.01.621",
     "step_therapy": "Some plan designs make you try phentermine or orlistat first. Six months of a documented lifestyle program is required.",
     "continuation": null,
     "policy_number": "5.01.621",
     "confidence": "medium",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Cardiovascular risk reduction (SELECT indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 27 or higher, with established cardiovascular disease",
     "step_therapy": "Wegovy is not on the drug list for most plans, so a request goes through the standard formulary exception process.",
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    }
   ],
   "sources": [
    {
     "url": "https://www.premera.com/medicalpolicies/5.01.621.pdf",
     "title": "Premera Blue Cross Pharmacy Policy 5.01.621, Drugs for Weight Management",
     "verified": "2026-06-12"
    },
    {
     "url": "https://providernews.premera.com/wegovy-coverage-with-the-new-cardiovascular-indication/",
     "title": "Premera Providers, Wegovy Coverage with the New Cardiovascular Indication",
     "verified": "2026-06-12"
    }
   ],
   "url": "https://glpchart.com/coverage/premera-wegovy/"
  },
  {
   "slug": "tricare-glp1",
   "payer": "TRICARE",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy, Zepbound, Saxenda (weight); Ozempic, Mounjaro (diabetes)",
   "plan_type": "TRICARE Prime and TRICARE Select",
   "status": "covered-with-PA",
   "answer": "Yes, on some plans. TRICARE pays for Wegovy, Zepbound and Saxenda for weight on Prime and Select, once your prescriber gets the plan to sign off. Members not on Prime or Select lost that coverage on August 31, 2025.",
   "employer_election": false,
   "policy_date": "2026-06-12",
   "indications": [
    {
     "label": "Obesity / weight management",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    },
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-06-12"
    }
   ],
   "sources": [
    {
     "url": "https://tricare.mil/FAQs/Pharmacy/PharmProg_Wegovy",
     "title": "TRICARE, Does TRICARE cover Wegovy, Ozempic, and Mounjaro? (Official TRICARE FAQ)",
     "verified": "2026-06-12"
    },
    {
     "url": "https://militaryrx.express-scripts.com/faq/are-glucagon-peptide-1-glp-1-and-weight-loss-medications-covered-through-tricare-pharmacy",
     "title": "Express Scripts TRICARE, Are GLP-1 and weight loss medications covered through the TRICARE pharmacy benefit?",
     "verified": "2026-06-12"
    }
   ],
   "url": "https://glpchart.com/coverage/tricare-glp1/"
  },
  {
   "slug": "tricare-mounjaro",
   "payer": "TRICARE",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "TRICARE Prime and TRICARE Select",
   "status": "covered-with-PA",
   "answer": "Yes, for type 2 diabetes. TRICARE pays for Mounjaro once your prescriber gets the plan to sign off. It is on the plan's GLP-1 diabetes list with Trulicity, Ozempic and Victoza. It is not covered for weight loss. Wegovy, Zepbound and Saxenda are the weight-loss drugs, and they are a separate benefit with their own rules.",
   "employer_election": false,
   "policy_date": "2026-08-31",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-31"
    }
   ],
   "sources": [
    {
     "url": "https://militaryrx.express-scripts.com/faq/are-glucagon-peptide-1-glp-1-and-weight-loss-medications-covered-through-tricare-pharmacy",
     "title": "Express Scripts for TRICARE, Are GLP-1 and weight-loss medications covered through the TRICARE pharmacy benefit",
     "verified": "2026-08-31"
    }
   ],
   "url": "https://glpchart.com/coverage/tricare-mounjaro/"
  },
  {
   "slug": "tricare-ozempic",
   "payer": "TRICARE",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "TRICARE Prime and TRICARE Select",
   "status": "covered-with-PA",
   "answer": "Yes, for type 2 diabetes. TRICARE pays for Ozempic once your prescriber gets the plan to sign off. It is on the plan's GLP-1 diabetes list with Trulicity, Mounjaro and Victoza. It is not covered for weight loss. Wegovy, Zepbound and Saxenda are the weight-loss drugs, and they are a separate benefit with their own rules.",
   "employer_election": false,
   "policy_date": "2026-08-31",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-08-31"
    }
   ],
   "sources": [
    {
     "url": "https://militaryrx.express-scripts.com/faq/are-glucagon-peptide-1-glp-1-and-weight-loss-medications-covered-through-tricare-pharmacy",
     "title": "Express Scripts for TRICARE, Are GLP-1 and weight-loss medications covered through the TRICARE pharmacy benefit",
     "verified": "2026-08-31"
    }
   ],
   "url": "https://glpchart.com/coverage/tricare-ozempic/"
  },
  {
   "slug": "united-healthcare-glp1",
   "payer": "UnitedHealthcare / OptumRx",
   "drug": "Wegovy and Zepbound",
   "drug_full": "Wegovy (semaglutide 2.4 mg), Zepbound (tirzepatide)",
   "plan_type": "Commercial job-based plans, both fully insured and self-funded",
   "status": "varies-by-plan",
   "answer": "Yes on some plans. UnitedHealthcare runs its weight-loss coverage as an optional program. Its own 2026 policy opens by calling it \"an optional program that is put in place for clients or businesses that have elected to cover weight loss products.\" If your employer bought that benefit, Wegovy and Zepbound are covered once the plan signs off. The bar is BMI 30, or BMI 27 with a weight-related condition. If your employer did not buy it, weight loss is excluded, and only three narrower routes are left: Wegovy for cardiovascular risk reduction, Wegovy for MASH, and Zepbound for sleep apnea.",
   "employer_election": true,
   "policy_date": "2026-08-15",
   "indications": [
    {
     "label": "Obesity / chronic weight management (plans that elected weight-loss coverage)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher, or above the 95th percentile for a child. BMI 27 or higher also qualifies with a weight-related condition. The policy names dyslipidemia, hypertension, type 2 diabetes and sleep apnea as examples.",
     "step_therapy": "None. The 2026 criteria do not make you try phentermine, orlistat or any other weight-loss drug first. They ask only that the drug be used alongside lifestyle change. The policy describes that as a restricted diet or fewer calories, exercise, behavioral support, or a community-based program. It sets no minimum length for it.",
     "continuation": "You lose 5 percent or more of the body weight you started with, and you keep up the lifestyle change",
     "policy_number": "2026 P 1114-21",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Cardiovascular risk reduction and MASH (Wegovy, plans without weight-loss coverage)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 27 or higher",
     "step_therapy": "No weight-loss drug has to be tried first. Instead the patient must already be on guideline-directed cardiovascular therapy from each class that applies, unless a drug is contraindicated or not tolerated. That means a cholesterol-lowering medication for all three histories, a beta blocker for a prior heart attack, an ACE inhibitor, ARB or ARNI, and an antiplatelet.",
     "continuation": null,
     "policy_number": "2026 P 1445-4",
     "confidence": "high",
     "verified_date": "2026-08-15"
    },
    {
     "label": "Obstructive sleep apnea (Zepbound, plans without weight-loss coverage)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": "PAP is the step, in effect. The patient has to still have obstructive sleep apnea symptoms while adhering to PAP, which the policy defines as at least 4 hours a night on at least 70 percent of nights. Or the record has to document that the patient is not a PAP candidate.",
     "continuation": "Under 52 weeks on the drug, any documented drop from baseline in the AHI, RDI or REI. At 52 weeks or more, a drop of 50 percent from baseline. Either way you also have to have lost 10 percent of your starting body weight.",
     "policy_number": "2025 P 1475-2",
     "confidence": "high",
     "verified_date": "2026-08-15"
    }
   ],
   "sources": [
    {
     "url": "https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/r-z/PA-Notification-Weight-Loss.pdf",
     "title": "UnitedHealthcare Pharmacy Clinical Pharmacy Programs, Prior Authorization/Notification: Plans with Weight Loss/Appetite Suppression Medication Coverage, Program 2026 P 1114-21, effective July 1, 2026",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/r-z/PA-Non-Formulary-Wegovy.pdf",
     "title": "UnitedHealthcare Pharmacy Clinical Pharmacy Programs, Prior Authorization/Non-Formulary: Wegovy (semaglutide) injection and tablets, Cardiovascular Risk Reduction and MASH Only, Program 2026 P 1445-4, effective May 1, 2026",
     "verified": "2026-08-15"
    },
    {
     "url": "https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/r-z/PA-Non-Formulary-Zepbound.pdf",
     "title": "UnitedHealthcare Pharmacy Clinical Pharmacy Programs, Prior Authorization/Non-Formulary: Zepbound (tirzepatide), Obstructive Sleep Apnea Only, Program 2025 P 1475-2, effective March 1, 2026",
     "verified": "2026-08-15"
    }
   ],
   "url": "https://glpchart.com/coverage/united-healthcare-glp1/"
  },
  {
   "slug": "united-mounjaro",
   "payer": "UnitedHealthcare / OptumRx",
   "drug": "Mounjaro",
   "drug_full": "Mounjaro (tirzepatide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "UnitedHealthcare covers Mounjaro for type 2 diabetes on its commercial plans, once the plan signs off. OptumRx handles that sign-off. To approve it, the plan asks for records confirming a type 2 diabetes diagnosis, and an approval runs 12 months. UnitedHealthcare will not cover Mounjaro for weight loss, because the FDA approved it for type 2 diabetes only. Zepbound is the weight-loss version of the same drug, tirzepatide, and UnitedHealthcare handles that one under a separate policy.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "2026 P 1332-8",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/a-g/PA-Notification-Diabetes-Agents-GLP1-Receptor-Agonists.pdf",
     "title": "UnitedHealthcare Pharmacy Clinical Pharmacy Programs. Prior Authorization/Notification: Diabetes Medications. GLP-1 & Dual GIP/GLP-1 Receptor Agonists",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/united-mounjaro/"
  },
  {
   "slug": "united-ozempic",
   "payer": "UnitedHealthcare / OptumRx",
   "drug": "Ozempic",
   "drug_full": "Ozempic (semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "UnitedHealthcare covers Ozempic for adults with type 2 diabetes on its 2026 commercial drug list. OptumRx runs the sign-off, and a quantity limit applies. Approval needs records confirming a type 2 diabetes diagnosis. An A1C of 6.5 percent or higher does that, and so does another qualifying lab value. For a patient diagnosed more than two years ago, chart notes are accepted. The 2026 policy has no step therapy, and an approval lasts 12 months. UnitedHealthcare does not cover Ozempic for weight loss. That use is off-label, and most plans leave it out. Weight loss is Wegovy's indication, the same semaglutide at a higher dose.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "2026 P 1332-8",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/a-g/PA-Notification-Diabetes-Agents-GLP1-Receptor-Agonists.pdf",
     "title": "UnitedHealthcare Pharmacy Clinical Pharmacy Programs. Prior Authorization/Notification: Diabetes Medications, GLP-1 & Dual GIP/GLP-1 Receptor Agonists. Program Number 2026 P 1332-8",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/united-ozempic/"
  },
  {
   "slug": "united-rybelsus",
   "payer": "UnitedHealthcare / OptumRx",
   "drug": "Rybelsus",
   "drug_full": "Rybelsus (oral semaglutide)",
   "plan_type": "Commercial non-Medicare",
   "status": "covered-with-PA",
   "answer": "UnitedHealthcare and OptumRx cover Rybelsus for type 2 diabetes on commercial plans, once the plan signs off. Approval needs medical records confirming a type 2 diabetes diagnosis. An A1C of 6.5% or higher does that. So does a fasting plasma glucose of 126 mg/dL or higher, or another qualifying glucose value. A patient diagnosed more than two years ago can qualify on records confirming the diagnosis. Rybelsus is not covered for weight loss. The FDA approved it for type 2 diabetes only, and plans usually leave weight-loss drugs out. Wegovy is the weight-loss version of semaglutide.",
   "employer_election": false,
   "policy_date": "2026-08-27",
   "indications": [
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": "2026 P 1332-8",
     "confidence": "high",
     "verified_date": "2026-08-27"
    }
   ],
   "sources": [
    {
     "url": "https://www.uhcprovider.com/content/dam/provider/docs/public/prior-auth/drugs-pharmacy/commercial/a-g/PA-Notification-Diabetes-Agents-GLP1-Receptor-Agonists.pdf",
     "title": "Prior Authorization/Notification: Diabetes Medications, GLP-1 and Dual GIP/GLP-1 Receptor Agonists",
     "verified": "2026-08-27"
    }
   ],
   "url": "https://glpchart.com/coverage/united-rybelsus/"
  },
  {
   "slug": "wellcare-medicare-glp1",
   "payer": "Wellcare (Centene) Medicare Advantage and Part D",
   "drug": "GLP-1 medications",
   "drug_full": "Wegovy, Zepbound, Ozempic, Mounjaro",
   "plan_type": "Medicare Advantage Part D and Medicare Part D",
   "status": "split",
   "answer": "No for weight loss alone. The 2003 Medicare Part D law bars it. Wellcare does cover Wegovy to lower cardiovascular risk, and Zepbound for sleep apnea. It covers the diabetes brands for type 2 diabetes. In each case the drug has to be on your own plan's drug list.",
   "employer_election": false,
   "policy_date": "2026-11-04",
   "indications": [
    {
     "label": "Wegovy for cardiovascular risk reduction (SELECT indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 27 or higher",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Zepbound for obstructive sleep apnea (SURMOUNT-OSA indication)",
     "status": "covered-with-PA",
     "bmi_threshold": "BMI 30 or higher",
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    },
    {
     "label": "Type 2 diabetes",
     "status": "covered-with-PA",
     "bmi_threshold": null,
     "step_therapy": null,
     "continuation": null,
     "policy_number": null,
     "confidence": "high",
     "verified_date": "2026-11-04"
    }
   ],
   "sources": [
    {
     "url": "https://www.wellcare.com/en/resources/does-medicare-cover-weight-loss-drugs",
     "title": "Wellcare, Does Medicare Cover Weight-Loss Drugs? Understanding GLP-1 Coverage in 2026",
     "verified": "2026-11-04"
    },
    {
     "url": "https://www.wellcare.com/en/resources/does-medicare-cover-weight-loss-drugs",
     "title": "Wellcare, Does Medicare Cover Weight-Loss Drugs? Understanding GLP-1 Coverage in 2026",
     "verified": "2026-11-04"
    },
    {
     "url": "https://www.wellcare.com/en/resources/does-medicare-cover-weight-loss-drugs",
     "title": "Wellcare, Does Medicare Cover Weight-Loss Drugs? Understanding GLP-1 Coverage in 2026",
     "verified": "2026-11-04"
    }
   ],
   "url": "https://glpchart.com/coverage/wellcare-medicare-glp1/"
  }
 ]
}