Prior authorization for Wegovy and Zepbound: what insurers require

Prior authorization is the second gate, not the first. Before any clinical criterion matters, your plan has to include weight-loss drugs at all, and many employer plans do not. UnitedHealthcare's own policy, effective October 1, 2026, opens by saying so: it is "an optional program that is put in place for clients or businesses that have elected to cover weight loss products." Cigna's coverage policies carry the same warning in their instructions: "a customer's benefit plan document always supersedes the information in the Coverage Policies."

So the first call is to your plan, with one question: are weight-loss medications a covered benefit, or an exclusion? If they are excluded, no amount of paperwork about your BMI changes the answer, and the section on other approved uses below is where to look. If they are covered, the criteria in the next sections are what your prescriber will be asked to document.

The commercial policies we read are organized around each drug's FDA-approved uses, and the labels are less specific than most people assume. Wegovy's label, revised June 2026, approves it for weight reduction in adults "with obesity" and adults "with overweight in the presence of at least one weight-related comorbid condition", for reducing the risk of heart attack, stroke and cardiovascular death in adults with established cardiovascular disease and obesity or overweight, and (the injection only) for MASH with moderate to advanced liver fibrosis. Zepbound's label, revised August 2026, approves it for weight reduction in the same two groups and for moderate to severe obstructive sleep apnea in adults with obesity.

Neither indication prints a BMI number. The familiar thresholds come from the trials described in section 14 of each label: Wegovy's Study 2 enrolled people "with obesity (BMI greater than or equal to 30 kg/m2) or with overweight (BMI 27 to 29.9 kg/m2) and at least one weight-related comorbid condition", as did three of its other adult weight trials, and Zepbound's weight trials used the same two cutoffs. (One Wegovy trial, in Japan and South Korea, enrolled at a BMI of 35, or 27 with two conditions.) The commercial policies we read use 30 and 27 as approval rules, but the label does not require those numbers, so a plan is free to set them higher, and some do.

Cigna and UnitedHealthcare publish their criteria openly; we read the current versions on October 28, 2026. They agree on the BMI floor and differ on most of what surrounds it.

Three details in those documents decide more approvals than the BMI does.

The baseline is your weight before any GLP-1. Cigna's policies repeat a note under every BMI criterion: it "refers to baseline prior to any glucagon-like peptide-1 (GLP-1) agonist." If you started a GLP-1 on cash pay and are now asking your plan to take over, the BMI that counts is the one recorded before you began, so keep that record.

Cigna wants three months of documented effort first. "Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months." A chart note from a visit where diet and activity were discussed and a plan was set is what a reviewer looks for. UnitedHealthcare asks that the drug be used alongside lifestyle modification and gives examples ("dietary or caloric restriction, exercise, behavioral support, community-based program") but sets no minimum period.

Renewal is a weight-loss test. Both insurers renew on a loss of at least 5% of starting weight. UnitedHealthcare's August 2026 revision added an exception: someone who has been on therapy six months or less and has not reached a maintenance dose gets a one-time six-month extension.

Cigna's policy library lists the GLP-1 weight-loss criteria in three versions, titled BMI 30, BMI 32 and BMI 35, and your plan's documents decide which one applies to you. In the BMI 35 version (policy IP0739, effective April 30, 2026), Wegovy requires a starting BMI of 35 or higher, or 27 or higher with at least two of the listed conditions rather than one. The age, the three-month lifestyle trial and the eight-month first approval are unchanged.

This is one reason two people with the same insurer card and the same BMI can get different answers. When you call, ask which criteria document your plan uses, by name or number, not just whether the drug is covered.

A plan that excludes weight-loss drugs can still cover these products for their other FDA-approved uses, under separate criteria.

Wegovy for heart-attack and stroke risk. UnitedHealthcare's non-formulary Wegovy program (2026 P 1445-4, effective May 1, 2026) exists for plans where "medications for the purpose of weight loss are typically a benefit exclusion." It approves Wegovy for cardiovascular risk reduction for 12 months in people 45 or older with a BMI of 27 or higher and a prior heart attack, a prior ischemic or hemorrhagic stroke, or symptomatic peripheral artery disease, who are already taking the standard medicines for that condition (a cholesterol-lowering drug, an ACE inhibitor, ARB or ARNI, and an antiplatelet drug, plus a beta blocker after a heart attack) unless they cannot. It excludes anyone with diabetes or an A1c above 6.5%. Cigna's criteria for the same use require age 18 or older, a BMI of 27 or higher, one of the same three events (a transient ischemic attack does not count) and optimized cardiovascular treatment.

Zepbound for sleep apnea. Cigna approves Zepbound for one year for moderate to severe obstructive sleep apnea with a starting BMI of 30 or higher and a sleep study showing an apnea-hypopnea index (or, on a home test, a respiratory event index) of 15 or more events per hour, excluding central sleep apnea and Cheyne-Stokes respiration. Renewal after a year needs a loss of at least 10% of starting weight, twice the bar for weight-loss renewal, and the prescriber's statement that sleep apnea signs or symptoms are stable.

Wegovy for MASH. Cigna requires stage F2 or F3 liver fibrosis shown by a biopsy within three years or by elastography or an ELF blood test (score 9.2 to 10.5) within six months, no cirrhosis, at least one metabolic risk factor managed to the standard of care, alcohol below set limits, and a prescription from or with an endocrinologist, gastroenterologist or hepatologist.

State Medicaid programs choose whether to cover anti-obesity drugs at all, and the rules change with state budgets. Two states show the range, both read from the state's own documents on October 28, 2026.

Michigan's letter also says coverage for indications other than obesity "will not be changing", which matches the pattern above: the heart, liver and sleep apnea uses are handled separately from weight loss. North Carolina's year shows why a tracker or an article (including this one) is not the place to confirm your state's rule. The state's current preferred drug list and its prior authorization criteria are.

Get your numbers on paper. Each criterion above has to be on record. You need a recorded height and weight from before any GLP-1, and a diagnosis for any condition that counts. Our weight and BMI screening page covers how BMI is measured, and the blood pressure, A1c and LDL cholesterol pages show the ranges that mark hypertension, diabetes and high cholesterol, three of the qualifying conditions.

Ask the plan three questions. Are weight-loss drugs a covered benefit? Which criteria document applies to my plan? Which product is preferred? Then give your prescriber the answers, along with notes from any visits where diet and activity were discussed in the past three months or more.

Price the fallback before you need it. If the answer is no, the manufacturers' cash prices are the alternative; our Wegovy and Zepbound cost guide carries every dose, and the GLP-1 cost calculator totals a year. Novo Nordisk's own pharmacy is profiled on our NovoCare Pharmacy page. Ozempic, the same molecule as Wegovy, is FDA-approved for type 2 diabetes, not weight loss, and its cash prices are in our Ozempic cost guide. For how each payer type treats these drugs, see our coverage guide, and for choosing between the two drugs, Zepbound vs Wegovy.