Coverage at a glance
| Indication | Coverage |
|---|---|
| Obesity / chronic weight management (Kaiser Permanente Northwest) | Covered with prior authorization |
| Obstructive sleep apnea (Kaiser Permanente Northwest) | Covered with prior authorization |
| Obesity / chronic weight management (Kaiser Permanente Mid-Atlantic States) | Covered with prior authorization |
| Obstructive sleep apnea (Zepbound, Kaiser Permanente Mid-Atlantic States) | Covered with prior authorization |
| Obesity / chronic weight management (Kaiser Permanente California) | Varies by plan |
| Obesity / chronic weight management (Kaiser Permanente Georgia) | Varies by plan |
| Weight-loss drugs (Kaiser Permanente Colorado) | Not covered |
| Weight-loss drugs (Kaiser Foundation Health Plan of Washington) | Varies by plan |
| Weight-loss drugs (Kaiser Permanente Hawaii) | Not covered |
| Anti-obesity medications (Kaiser Permanente FEHB plans) | Varies by plan |
If your plan denies coverage, two cash programs to check.
No insurance needed.
- Strut Health$149 a month, with auto-refillcompounded semaglutideCheck price →You pick Weight Loss, then a five-minute online visit
- Shed$199 a monthcompounded semaglutideCheck price →Every medication is listed with a starting price
Cheapest GLP-1 without insurance compares the three cash routes. Cheapest GLP-1 ranks every cash price on the chart.
Prior authorization: the plan reviews the prescription before it pays. Non-formulary: not on the plan's covered-drug list, so it takes an exception.
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. This answer covers Commercial HMO, marketplace and small or large group plans across the Kaiser regional health plans.
Source: 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. Checked August 15, 2026.
Where your plan lists it. Wegovy is on the formulary at Tier 2 in every strength, including Wegovy HD 7.2 mg. Source: 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.
What it costs once they say yes. With commercial insurance the manufacturer savings card takes Wegovy or Zepbound to as little as $25 a month. Your plan sets the copay before the card applies. What Wegovy costs with your plan. What Zepbound costs with your plan.
This varies by plan. Kaiser states the benefit gate in the rules document itself. The Northwest criteria for Wegovy open with a note. The drug "is covered under the prescription drug benefit for weight loss ONLY for Kaiser Northwest members with coverage for medications used to treat weight loss. Others pay member cash price." The Kaiser Permanente Washington drug lists say most plans leave weight-loss drugs out. The Hawaii individual and family Evidence of Coverage puts "Drugs used for weight management" under Services Not Covered. So call member services on the number on your card, and ask whether your plan covers drugs used for weight loss. Or read the prescription drug part of your Evidence of Coverage.
Separately licensed regional plans. Kaiser Permanente is not one insurer. The documents on this page come from six separate legal entities. Oregon and southwest Washington run under Kaiser Foundation Health Plan of the Northwest. The rest of that state runs under Kaiser Foundation Health Plan of Washington. Virginia, Maryland and DC run under Kaiser Foundation Health Plan of the Mid-Atlantic States. Colorado runs under Kaiser Foundation Health Plan of Colorado, and Georgia under Kaiser Foundation Health Plan of Georgia. Northern California, Southern California and Hawaii all run under Kaiser Foundation Health Plan, Inc.
Coverage by indication
The document defines an adequate trial as 3 months of treatment.
| 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 |
| Authorization length | 12 months initial, reviewed every 12 months |
What the prior authorization needs:
- Your plan must include the prescription drug benefit that covers medications used to lose weight
- Age 18 or older for the adult pathway
- Weight and BMI documented within about the last 30 days
- Actively making lifestyle changes (diet or exercise) or holding an active behavioral health referral for that purpose
- No personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2
- The Wegovy shot and the Wegovy tablet are both on the drug list. Zepbound is not on the drug list, and it needs a clinical review
- The Wegovy tablet pathway also requires failing Ozempic and then Wegovy injectable, unless the patient has needle phobia or cannot inject safely
Source: 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. Kaiser's own regional criteria PDF, read in full.
The criteria for the Wegovy shot carry the same sleep-apnea route, at the same thresholds.
| BMI threshold | BMI 30 or higher |
| Sleep study (AHI) | Severe sleep apnea only. The criteria draw that line at an apnea-hypopnea index of 30 or greater |
| 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 |
| Authorization length | 12 months initial, reviewed every 12 months |
What the prior authorization needs:
- Age 18 or older
- Sleep study within the last 5 years
- No central or complex sleep apnea
- No diabetes diagnosis
- Weight and BMI documented within about the last 30 days
- Actively making lifestyle changes or holding an active behavioral health referral
Source: Kaiser Permanente Northwest Region Criteria for Drug Coverage, tirzepatide (Zepbound), Criteria-Based Consultation Prescribing Program, revised June 11 2026, effective June 18 2026. Kaiser's own regional criteria PDF, read in full.
One form covers all three drugs. It states its own scope. The form is used "for coverage of Weight Management Agents (Wegovy, Saxenda, & Zepbound) for Commercial, Exchange, and FEHB (Federal) plans." In March 2024 Mid-Atlantic told network providers to put in a referral first. That goes to its Pharmacy Weight Management Service, and it goes in before anyone prescribes an injected weight-loss drug. It also said a patient who does not meet the criteria will not be enrolled, and will be offered other options.
| 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 |
| Authorization length | 6 months initial, 6 months continuation |
What the prior authorization needs:
- Enrollment in the KPMAS Clinical Pharmacy Weight Management Service, or the prescription written by an endocrinologist or a weight management specialist
- Age 12 or older for Wegovy and Saxenda, 18 or older for Zepbound
- Documented baseline weight
- Currently enrolled in or following a lifestyle intervention program, internal or external, and continuing it on the drug
- Not used in combination with another weight-loss drug or another GLP-1 or GIP/GLP-1 agent
Source: 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. Kaiser's own sign-off form PDF, all 5 pages read in full.
The form ties its exclusion list straight to the SURMOUNT-OSA trial. It says those patients were kept out of the trial, so there is no evidence to cover them. There is also a separate Mid-Atlantic Zepbound form, and that one applies to Maryland Medicaid plans and to nothing else. It sets a sleep-apnea route at an apnea-hypopnea index of 15 or higher, with a BMI of 30 or higher. It will not renew below BMI 30.
| BMI threshold | Baseline BMI 35 or higher |
| Sleep study (AHI) | Moderate sleep apnea at an apnea-hypopnea index of 15 to 29, or severe at 30 or above |
| 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 |
| Authorization length | 6 months initial, 6 months continuation |
What the prior authorization needs:
- Age 18 or older
- Enrollment in the KPMAS Pharmacy Weight Management Service, or the prescription written by a pulmonologist or a weight management specialist
- Enrolled in or following a lifestyle intervention program and continuing it on the drug
- Not prescribed another GLP-1 or GIP/GLP-1 agent at the same time
- None of the SURMOUNT-OSA exclusions apply: type 1 or type 2 diabetes, central or mixed sleep apnea, prior or planned surgery for sleep apnea or obesity, significant renal, pulmonary or liver disease, prior pancreatitis, or a personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2
Source: 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. Kaiser's own sign-off form PDF.
Wegovy is on both California commercial drug lists we read. One of them is the 2026 California Commercial Marketplace Formulary, and the other is the 2026 Southern California Commercial HMO Formulary. Both were updated on August 1, 2026, and both took effect on August 4, 2026. Every strength sits at Tier 2, with nothing in the coverage requirements column. The California code key runs QL, LD, OC, PREV and MB. There is no prior-authorization code in it. Zepbound and tirzepatide are not in either document at all. Kaiser's own front matter points the coverage question back at the plan. The drug list "does not provide information regarding specific coverage, exclusions, copays, or coinsurances," and it tells members to go and read the Evidence of Coverage.
What the prior authorization needs:
- Wegovy is on the formulary at Tier 2 in every strength, including Wegovy HD 7.2 mg
- Zepbound is not on either California commercial list
- Kaiser does not publish the California clinical criteria
Source: 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. Kaiser's own drug list PDF.
Kaiser Permanente of Georgia runs a five-tier drug benefit for 2026, current as of July 8, 2026. It lists Wegovy, Zepbound and Saxenda together at Tier 5, with the same two codes on each. Its own tier key reads "Tier 1=Preventative Generic, Tier 2=Preferred Generic, Tier 3=Preferred Brand, Tier 4=Non-preferred Drugs, Tier 5=Specialty". The document does not publish what sits behind the PA code.
What the prior authorization needs:
- Wegovy: Tier 5, coded PA and QL
- Zepbound: Tier 5, coded PA and QL
- Saxenda: Tier 5, coded PA and QL
- Tier 5 is the specialty tier in the document's own key
Source: Kaiser Permanente of Georgia 2026 Five-Tier Formulary Benefit, current as of July 8 2026, Wegovy Zepbound and Saxenda entries plus the tier key. Kaiser's own drug list PDF.
Kaiser Permanente Colorado has two drug lists for 2026, one commercial and one marketplace. Both were revised on July 21, 2026. Neither Wegovy nor Zepbound is on either one. The anti-obesity entries on those lists are phentermine and phentermine-topiramate. Ozempic is listed for diabetes. The Colorado list spells out what being off it means. "Drugs not listed on the formulary are referred to as non-preferred or non-formulary drugs and are not covered unless Kaiser Permanente determines that they are medically necessary through the formulary exception process." There is also a separate list for the self-funded EPO, where Optum Rx runs the drug benefit. That one carries neither drug either.
Source: Kaiser Permanente Colorado Commercial Formulary (List of Covered Drugs), revision date July 21 2026, weight reduction section and the non-formulary drug rule. Kaiser's own drug list PDF.
Kaiser Permanente Washington has two commercial drug lists in force from August 2026. One is for individuals and small groups. The other is the large group three-tier list. Both put Zepbound and the Zepbound KwikPen at Tier 3, with a prior-authorization code and a quantity limit. Wegovy is on neither. Both documents also carry the same benefit warning up front. Most plans leave out "drugs for anticipated illnesses while traveling, drugs for weight loss, and drugs used for cosmetic purposes." Kaiser publishes no Washington coverage criteria behind the PA code.
What the prior authorization needs:
- Zepbound and Zepbound KwikPen: Tier 3, coded PA and QL
- Wegovy: not listed on either 2026 commercial formulary
- Zepbound appearing on the list does not by itself establish that your plan covers weight-loss drugs
- Non-formulary drugs are not covered unless the plan approves a coverage exception
- Kaiser Foundation Health Plan of Washington is a different plan from Kaiser Foundation Health Plan of the Northwest, which covers Oregon and southwest Washington
Source: 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. Kaiser's own drug list PDF, pulled in table mode.
In Hawaii, the 2026 Evidence of Coverage for plans you buy yourself has a line under Services Not Covered. It reads "Drugs used for weight management," and it sits in the prescription drug chapter. A second exclusion in the same document rules out weight reduction programs "whether or not weight reduction is medically appropriate," drugs and supplies included. Kaiser Permanente Hawaii also has a marketplace drug list, in force from August 1, 2026. That one carries Ozempic and Victoza for diabetes. It does not carry Wegovy, Zepbound or Saxenda at all. Group plan documents can differ.
Source: 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. Kaiser's own Evidence of Coverage PDF, read in full.
Kaiser Permanente Northwest's 2026 FEHB brochure prices drugs prescribed to treat obesity at 50 percent of the plan allowance. That holds on the High Option, Standard Option and Prosper plans. The brochure flags it as a change for 2026. "We increased the amount you pay for a 30-day supply of anti-obesity medications and for GLP-1 drugs prescribed for weight loss management to 50% of our Plan allowance." The 2026 FEHB drug list for Colorado, revised July 21, 2026, is narrower than that. Under anti-obesity GLP-1 receptor agonists it carries one drug, generic liraglutide for weight loss. Neither Wegovy nor Zepbound is there.
What the prior authorization needs:
- Northwest FEHB: you pay 50 percent of the plan allowance for medications prescribed to treat obesity, on the High Option, Standard Option and Prosper plans
- Colorado FEHB: the only anti-obesity GLP-1 listed is generic liraglutide for weight loss at Tier 1 with prior authorization
- Mid-Atlantic FEHB: covered under the same weight management agents prior-authorization form as commercial and exchange plans
- The Northwest brochure's condition is that the drug is 'prescribed as indicated by the FDA obesity medication treatment guidelines'
Source: 2026 Kaiser Permanente Northwest FEHB plan brochure RI 73-004, Section 5(f) prescription drug benefits and the 2026 changes summary. The plan brochure PDF the US Office of Personnel Management publishes, downloaded from opm.gov and read in full.
Recent change: Kaiser Permanente Northwest rewrote its Wegovy and Zepbound criteria, effective June 18, 2026. It still publishes the older versions at their own web addresses. The Wegovy shot was non-formulary in the criteria revised September 11, 2025, and it is formulary in the ones that run now. The step-therapy rule loosened. It used to require a trial of every oral drug on the list. It now requires a trial of at least two of them. The rule that made you try Ozempic first was dropped from the Wegovy shot criteria. The sleep-apnea route widened its sleep-study lookback from 3 years to 5 years. That route now shows up for Wegovy as well as Zepbound.
Ozempic and Mounjaro on Kaiser Permanente plans
Ozempic and Mounjaro are approved for type 2 diabetes, not weight loss.
Does Kaiser cover Ozempic?
Yes, with prior approval. Kaiser pays for Ozempic once your prescriber gets the plan to sign off.
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.
Checked August 27, 2026.
What Kaiser requires for Ozempic
| Step therapy | Required |
What the prior authorization needs:
- Prior authorization required through Kaiser's Criteria-Based Consultation Prescribing Program
- Documented type 2 diabetes diagnosis
- No personal or family history of medullary thyroid carcinoma or MEN 2
- On maximally tolerated metformin, or intolerance or contraindication to it
- Trial of at least two added diabetes drugs (sulfonylurea, pioglitazone, or an SGLT2 inhibitor) and, in most pathways, liraglutide
- A1C or glucose management indicator still above 6.9% after an adequate 3-month trial
- Quantity limits apply
Source: Injectable semaglutide (Ozempic): Criteria for Drug Coverage, Kaiser Permanente Northwest Region. The plan's own coverage policy.
Recent change: Kaiser Northwest's commercial criteria for Ozempic, in force from 07/01/26, carry type 2 diabetes routes and nothing else. An earlier version, in force from 11/06/25, also carried a chronic weight management route. That one was open only to members whose plan covered weight-loss drugs.
Does Kaiser cover Mounjaro?
Yes, with prior approval. Kaiser pays for Mounjaro once your prescriber gets the plan to sign off.
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.
Checked August 27, 2026.
What Kaiser requires for Mounjaro
| Step therapy | Required |
What the prior authorization needs:
- The plan signs off through Kaiser's Criteria-Based Consultation Prescribing Program. Mounjaro is not on the drug list, but it can be covered where the criteria are met.
- Diagnosis of type 2 diabetes.
- No personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2).
- You are on semaglutide at the maximum tolerated dose, 2 mg once a week, for at least 3 months, or it has failed you. A contraindication to semaglutide counts instead, and so does an intolerance.
- You are on the highest dose you can tolerate of metformin, a sulfonylurea, pioglitazone and an SGLT2 inhibitor, or you cannot tolerate them.
- A1C (or GMI) still above 6.9% and below 10% after an adequate trial (about 3 months) of the therapies above.
- Quantity limits apply.
Source: Kaiser Permanente Northwest Region, Criteria for Drug Coverage: tirzepatide (Mounjaro). The plan's own covered-drug list.
Recent change: Kaiser Northwest revised its tirzepatide (Mounjaro) criteria on 02/12/26, and they took effect on 03/05/26.
Important exclusions
- Kaiser Permanente Hawaii: the 2026 individual and family Evidence of Coverage lists drugs used for weight management under Services Not Covered, and neither drug is on the Hawaii marketplace formulary
- Kaiser Permanente Colorado: neither Wegovy nor Zepbound is on the 2026 commercial or marketplace formulary, and the formulary states that unlisted drugs are not covered without a medical-necessity exception
- Kaiser Permanente Washington: Wegovy is not on either 2026 commercial formulary, and the formularies say most plans exclude drugs for weight loss
- Kaiser Permanente California: Zepbound and tirzepatide do not appear anywhere on the 2026 California commercial marketplace or Southern California commercial HMO formularies
- This page covers commercial, marketplace and FEHB plans. Kaiser's Medicare Part D formulary is a separate document with different rules
What to do next
If you qualify under one of the covered indications above, prior authorization is the path. Match the documentation in the requirements list then have your prescriber submit it. Plans that approve reassess at renewal, so know your long-term maintenance dose before you start.
- Start with the Kaiser Permanente prior-authorization letter template, which cites this plan's policy and the diagnosis codes a reviewer looks for. Pick the indication that matches your clinical picture.
- Read why plans say no and the four ways to appeal in the GLP-1 insurance guide.
- Your plan may treat another GLP-1 differently. The Kaiser Permanente coverage check lists all 3, with the source for each.
- If the plan denies it, the appeal letter library has a template for each reason a plan gives. That covers the peer-to-peer call with a plan doctor, the Level 1 and Level 2 appeals inside the plan, and the outside review that follows them.
- Call the number on your insurance card and ask whether your specific plan includes the weight-management drug benefit before you submit.
- If your plan does not cover the indication you need, compare cash prices in the cost guide or check whether a clinical trial near you fits. Neither one goes through your insurer. Clinical trials cost nothing and many pay you for your time.
What it costs without insurance
The programs below bill you directly. Prices checked every Monday.
Frequently asked questions
Does Kaiser Permanente cover Wegovy for weight loss?
In some regions, and in the Northwest only if your plan includes the weight-loss drug benefit. Wegovy is on the formulary at Tier 2 on both 2026 California commercial drug lists and at Tier 5 with prior authorization and a quantity limit in Georgia. Kaiser Permanente Northwest made Wegovy injectable formulary in its June 18, 2026 criteria, approving it at BMI 30 or higher, or BMI 27 or higher with one of eleven listed conditions, after a failed 3-month trial of at least two oral weight-loss agents. Colorado, Hawaii and Kaiser Permanente Washington do not list it. The Northwest criteria say members whose plan does not include that benefit pay the member cash price.
Does Kaiser Permanente cover Zepbound?
Less often than Wegovy. In the Northwest, Zepbound is non-formulary and needs a clinical review, and the criteria require a failed minimum 6-month trial of semaglutide plus a bariatric medicine chart review before the switch is approved. In Mid-Atlantic, Zepbound sits on the same prior-authorization form as Wegovy but adds a 3-month Wegovy trial and a minimum 16-week washout off all GLP-1 medication first. Georgia lists Zepbound at Tier 5 with prior authorization. Kaiser Permanente Washington lists Zepbound and Zepbound KwikPen at Tier 3 with prior authorization and a quantity limit. California, Colorado and Hawaii do not list Zepbound on their commercial formularies at all.
What BMI does Kaiser Permanente require for GLP-1 coverage?
It depends on the region and the indication, and two Kaiser regions publish BMI numbers. Kaiser Permanente Northwest uses BMI 30 or higher, or BMI 27 or higher with one of eleven listed conditions including pre-diabetes, sleep apnea, chronic kidney disease and polycystic ovarian syndrome. Its sleep-apnea pathway uses BMI 30 or higher plus an apnea-hypopnea index of 30 or greater, which is severe sleep apnea only. Kaiser Permanente Mid-Atlantic uses the same BMI 30 or 27-with-a-condition rule for weight management, then raises the bar to BMI 35 for the Zepbound sleep-apnea pathway and accepts an apnea-hypopnea index of 15. California, Georgia and Kaiser Permanente Washington do not publish clinical criteria for these drugs.
Why might Kaiser deny Wegovy even if my BMI qualifies?
Four reasons. First, your plan may not include the weight-loss drug benefit, which the Northwest criteria and the Washington formularies both flag on their face. Second, the drug may not be on your region's formulary. Colorado and Hawaii list neither Wegovy nor Zepbound, and Colorado's rule for unlisted drugs is that they are not covered without a medical-necessity exception. Third, the step therapy. Northwest and Mid-Atlantic, the two regions that publish criteria, both require a documented trial of the older oral agents first, and Mid-Atlantic adds a 3-month Wegovy trial at the maximum tolerated dose. Fourth, Mid-Atlantic wants the prescription to come through its own Clinical Pharmacy Weight Management Service, or from an endocrinologist or a weight management specialist.
Does Kaiser Permanente cover Zepbound for sleep apnea?
Yes, with prior authorization. The criteria for the Wegovy shot carry the same sleep-apnea route, at the same thresholds. Kaiser Permanente states this in Kaiser Permanente Northwest Region Criteria for Drug Coverage, tirzepatide (Zepbound), Criteria-Based Consultation Prescribing Program, revised June 11 2026, effective June 18 2026, read August 2026.
Coverage for other payers
See the full payer coverage index for every plan we have sourced.
How we built this page
Every page here comes from the payer's own policy, a federal law, or KFF's plan research. Each row links its source and gives the date we read it. Some plan files load at the address the payer gives but will not open. We check those against a second source and mark the row lower confidence. Job-based plans also choose whether to add the weight-drug benefit at all, so those rows say varies by plan rather than a flat yes.
This is reference information, not medical or legal advice, and not a guarantee of coverage. GLP-1 coverage policies change often. Always confirm the current policy with your insurer using the number on your card before you rely on this page. If your experience differs from what is shown here, email hello@glpchart.com with the details and we will re-verify.
