Coverage at a glance
| Indication | Coverage |
|---|---|
| Obesity / chronic weight management (Kaiser Permanente Northwest) | Covered with PA |
| Obstructive sleep apnea (Kaiser Permanente Northwest) | Covered with PA |
| Obesity / chronic weight management (Kaiser Permanente Mid-Atlantic States) | Covered with PA |
| Obstructive sleep apnea (Zepbound, Kaiser Permanente Mid-Atlantic States) | Covered with PA |
| 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 |
Plan type: Commercial HMO, marketplace and small or large group plans across the Kaiser regional health plans. Each indication below lists the BMI and clinical thresholds, the prior-authorization documentation, and the published policy it comes from.
This varies by plan. Kaiser states the benefit gate in the criteria document itself. The Northwest criteria for Wegovy open with a note that 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 formularies say that most plans exclude drugs for weight loss. The Hawaii individual and family Evidence of Coverage lists "Drugs used for weight management" under Services Not Covered. Ask member services on the number on your card whether your plan includes coverage for weight-loss medications, or read the prescription drug section of your Evidence of Coverage.
One BCBS company, not all. Kaiser Permanente is not one insurer. The documents on this page are published by separate legal entities: Kaiser Foundation Health Plan of the Northwest (Oregon and southwest Washington), Kaiser Foundation Health Plan of Washington (the rest of the state), Kaiser Foundation Health Plan of the Mid-Atlantic States (Virginia, Maryland, DC), Kaiser Foundation Health Plan of Colorado, Kaiser Foundation Health Plan of Georgia, and Kaiser Foundation Health Plan, Inc. in Northern California, Southern California and Hawaii.
Coverage by indication
The document defines an adequate trial as 3 months of treatment.
| BMI threshold | BMI 30 or higher, or BMI 27 or higher with at least one documented condition from an 11-item list: 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. Patients aged 12 to 17 qualify at BMI 35 or higher, with a qualifying comorbidity. |
| Step therapy | A failed 3-month trial of at least two of phentermine, diethylpropion, topiramate, Qsymia or Contrave, or an allergy, intolerance or contraindication to all of them. Zepbound carries a second step on top of that: a failed minimum 6-month trial of semaglutide (Ozempic or Wegovy) followed by a bariatric medicine chart review to decide whether the switch is necessary, or a documented allergy, intolerance or contraindication to semaglutide. |
| 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
- Wegovy injectable and Wegovy tablet are formulary. Zepbound is non-formulary and 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. Official regional coverage criteria PDF (downloaded from healthy.kaiserpermanente.org and read in full). The Zepbound step-therapy and non-formulary status were read from the matching tirzepatide (Zepbound) criteria document at the same path, and the Wegovy tablet steps from the semaglutide tablet document.. Verified August 15, 2026.
The Wegovy injectable criteria carry the same sleep-apnea pathway, with the same thresholds.
| BMI threshold | BMI 30 or higher |
| Sleep study (AHI) | Severe sleep apnea only, which the criteria define as an apnea-hypopnea index of 30 or greater. |
| Step therapy | The oral-agent step is the same as the weight-management pathway. A failed 3-month trial of at least two of phentermine, diethylpropion, topiramate, Qsymia or Contrave, or an allergy, intolerance or contraindication to all of them. 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. Official regional coverage criteria PDF (downloaded from healthy.kaiserpermanente.org and read in full; the parallel Wegovy injectable sleep-apnea criteria were read from the semaglutide injectable document at the same path). Verified August 15, 2026.
One form covers all three drugs. It states its own scope: it is used "for coverage of Weight Management Agents (Wegovy, Saxenda, & Zepbound) for Commercial, Exchange, and FEHB (Federal) plans." Mid-Atlantic told network providers in March 2024 to place a Pharmacy Weight Management Service referral before prescribing an injectable weight-loss medication, and said patients who do not meet criteria will not be enrolled and will be offered alternatives instead.
| 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 | Documented intolerance, contraindication, or failure to lose and maintain 5 percent or more of body weight after a 3-month trial of all of phentermine, Qsymia and Contrave. Saxenda and Zepbound add a fourth step: a 3-month trial of Wegovy at the maximum tolerated dose. A Zepbound request also requires a minimum 16-week period off all GLP-1 and GIP/GLP-1 medication first, spent on lifestyle changes. |
| 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. Official payer prior-authorization form PDF (downloaded from healthy.kaiserpermanente.org and read in full, all 5 pages; Kaiser updates this file in place, so the URL still carries a 2024 path and a Wegovy and Saxenda filename while the document itself is the September 22 2025 revision covering Zepbound as well). The referral requirement was cross-read from Kaiser Permanente Network News, March 2024, at the same domain.. Verified August 15, 2026.
The form ties its exclusion list directly to the SURMOUNT-OSA trial, saying those patients were excluded from the trial and so there is no evidence to cover them. A separate Mid-Atlantic Zepbound form at healthy.kaiserpermanente.org applies to Maryland Medicaid plans only. It sets a sleep-apnea pathway at apnea-hypopnea index 15 or higher and BMI 30 or higher, and 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. Official payer prior-authorization form PDF (downloaded and read in full; the URL keeps a 2024 path and an older filename because Kaiser updates the file in place). The Maryland Medicaid comparison was read from the Zepbound (tirzepatide) Prior Authorization form at the same domain, revision date July 7 2025.. Verified August 15, 2026.
Wegovy appears on both California commercial drug lists we read: the 2026 California Commercial Marketplace Formulary and the 2026 Southern California Commercial HMO Formulary, both updated August 1, 2026 and effective 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, with no prior-authorization code in it. Zepbound and tirzepatide do not appear anywhere in either document. Kaiser's own front matter points the coverage question back at the plan: the formulary "does not provide information regarding specific coverage, exclusions, copays, or coinsurances," and directs members to 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. Official payer formulary PDF (downloaded from healthy.kaiserpermanente.org; the drug-name, tier and coverage-requirement columns were extracted in table mode so each tier maps to its own drug row rather than to a neighboring row). Cross-checked against the 2026 Southern California Commercial HMO Formulary at the same domain, which shows the same Tier 2 placement and the same absence of Zepbound.. Verified August 15, 2026.
Kaiser Permanente of Georgia's 2026 five-tier formulary benefit, current as of July 8, 2026, lists Wegovy, Zepbound and Saxenda together at Tier 5 with the same two codes on each. The document's 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 the clinical content 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. Official payer formulary PDF (downloaded from healthy.kaiserpermanente.org and extracted in table mode so tier and code map to the named drug row). Verified August 15, 2026.
Neither Wegovy nor Zepbound appears on Kaiser Permanente Colorado's 2026 commercial formulary or its 2026 marketplace formulary, both revised July 21, 2026. The anti-obesity entries on those lists are phentermine and phentermine-topiramate. Ozempic is listed for diabetes. The Colorado formulary states the consequence of not being listed: "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." The separate self-funded EPO formulary, where Optum Rx administers the pharmacy benefit, lists 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. Official payer formulary PDF (downloaded from healthy.kaiserpermanente.org and read in full for every Wegovy, Zepbound, tirzepatide and Saxenda string). Cross-checked against the Kaiser Permanente Colorado Commercial Marketplace Formulary of the same revision date and the Colorado EPO self-funded formulary, both of which also list neither drug.. Verified August 15, 2026.
Both Kaiser Permanente Washington commercial formularies effective August 2026, the individual and small group list and the large group three-tier list, place Zepbound and Zepbound KwikPen at Tier 3 with a prior-authorization code and a quantity limit. Wegovy does not appear on either. Both documents also carry the same benefit warning in their front matter: most plans exclude "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. Official payer formulary PDF (downloaded from healthy.kaiserpermanente.org and extracted in table mode). Cross-checked against the Kaiser Permanente Washington 2026 Drug Formulary for large employer groups with a 3-tier in-network benefit, effective August 2026, which carries the identical Zepbound placement and the identical exclusions paragraph.. Verified August 15, 2026.
The Hawaii individual and family Evidence of Coverage for 2026 lists "Drugs used for weight management" as a line item under Services Not Covered in the prescription drug chapter. A second exclusion in the same document removes weight reduction programs 'whether or not weight reduction is medically appropriate,' including drugs and supplies. Kaiser Permanente Hawaii's marketplace drug formulary effective August 1, 2026 lists Ozempic and Victoza for diabetes and does not list Wegovy, Zepbound or Saxenda anywhere. 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. Official payer Evidence of Coverage PDF (downloaded from healthy.kaiserpermanente.org and read in full). Cross-checked against the Kaiser Permanente Hawaii Marketplace Drug Formulary effective August 1 2026, which lists neither drug.. Verified August 15, 2026.
Kaiser Permanente Northwest's 2026 FEHB brochure lists medications prescribed to treat obesity at 50 percent of plan allowance across the High Option, Standard Option and Prosper plans, and flags that as a 2026 change: "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." Kaiser Permanente Colorado's 2026 FEHB formulary, revised July 21, 2026, is narrower. Under anti-obesity GLP-1 receptor agonists it carries only generic liraglutide for weight loss, and neither Wegovy nor Zepbound appears.
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. Official plan brochure PDF published by the US Office of Personnel Management (downloaded from opm.gov and read in full). The Colorado comparison was read from the 2026 Kaiser Permanente Federal Employees Health Benefit Drug Formulary, Colorado Region, at healthy.kaiserpermanente.org.. Verified August 15, 2026.
Recent change: Kaiser Permanente Northwest rewrote its Wegovy and Zepbound criteria effective June 18, 2026. Kaiser still publishes the prior versions at their own URLs. Wegovy injectable was non-formulary in the criteria revised September 11, 2025 and is formulary in the current ones. The step-therapy rule loosened from a trial of every listed oral agent to a trial of at least two of them, and the mandatory Ozempic step was dropped from the Wegovy injectable criteria. The sleep-apnea pathway widened its sleep-study lookback from 3 years to 5 years and now appears for Wegovy as well as Zepbound.
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 the full coverage picture, denial reasons, and the four appeal pathways at GLP-1 insurance coverage.
- If the prior-authorization request is denied, the appeal letter library has templates by denial reason, covering peer-to-peer review, Level 1 and Level 2 internal appeal, and external review.
- 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. Some participants get a placebo, decided at random.
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.
Coverage for other payers
See the full payer coverage index for every plan we have sourced.
How we built this page
Each page is built from a published payer policy document, government statute, or independent formulary analysis (KFF). Every indication row carries the source URL and the date we verified it. Where a payer's policy PDF was confirmed at its public URL but served as an unreadable binary, the policy number and coverage framework were cross-checked against secondary sources; those rows are marked lower confidence. Commercial coverage often depends on whether an employer elected the weight-management benefit. 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.
