What is the minimum BMI to qualify for Wegovy or Zepbound?
BMI of 30 or higher (obesity), OR BMI of 27 or higher (overweight) plus at least one weight-related health condition like hypertension, type 2 diabetes, or high cholesterol. Insurance companies generally follow these same FDA thresholds.
What counts as a "weight-related comorbidity"?
Type 2 diabetes, high blood pressure, high cholesterol or triglycerides, obstructive sleep apnea, and cardiovascular disease. Your doctor determines which conditions apply to your situation.
Do I need to have diabetes to get Ozempic?
For insurance coverage, almost always yes. Ozempic is FDA-approved for type 2 diabetes only. Doctors can prescribe it off-label for weight loss, but insurance rarely pays for that. You'd be paying cash.
What is "step therapy" and why does my insurance require it?
Step therapy means your insurer requires you to try cheaper drugs first (like metformin for diabetes) before they'll cover a GLP-1. It's a cost-control measure. It can delay your access to the drug your doctor actually wants you on.
Can I get a GLP-1 if I only want to lose 15-20 pounds?
FDA criteria are based on BMI, not a target number of pounds. If your BMI is below 27, you don't meet the approved criteria for weight management GLP-1s, regardless of your weight loss goal. Doctors are unlikely to prescribe outside these thresholds.
How do I prove to my insurance that I meet the criteria?
Your doctor submits documentation during prior authorization: current BMI (height and weight), diagnosis codes for diabetes or weight-related conditions, lab results (like A1c), and records of previous treatments tried. Having your complete medical records ready strengthens your case.
Are the eligibility rules different for teens?
Some GLP-1 medications have FDA approval for adolescents 12 and older for specific indications. Eligibility criteria may differ from adult standards, and insurance coverage varies by plan. A pediatric specialist should be involved for patients under 18.
