News

GLP-1 medications such as Wegovy® and Zepbound® continue to be one of the most discussed topics during renewals and prospect meetings.

While many carriers offer some form of weight-loss drug coverage, eligibility is typically tied to employer plan design, pharmacy benefits, medical necessity criteria, prior authorization requirements, and ongoing clinical management. For many employers, the key question is no longer whether GLP-1s are available, but how much access they want to provide and how they plan to manage the associated costs.

Most carriers share several common requirements:
-    Coverage is not automatically included in every group medical plan.
-    Prior authorization is almost always required.
-    Members generally must meet BMI and/or medical necessity criteria established by the carrier.
-    Many carriers require ongoing treatment monitoring and may periodically reassess eligibility.
-    Coverage for diabetes medications such as Ozempic® or Mounjaro® does not necessarily mean coverage for weight-loss treatment.

Questions about GLP-1 coverage? Your Dickerson Sales Representative can help you compare carrier approaches, review plan-specific coverage considerations, and identify solutions that align with your clients' benefits and budget goals.

Aetna

Coverage Available?
Yes. Employers can choose whether to include obesity-management coverage within their pharmacy benefit structure. Coverage ultimately depends on the employer's selected plan design.

Qualification Requirements
Members generally must satisfy Aetna's clinical criteria and obtain prior authorization. Medical necessity reviews and physician documentation are commonly required.

What's Covered?
Eligible plans may cover FDA-approved anti-obesity medications, including GLP-1 therapies selected within the employer's formulary. Coverage varies by pharmacy benefit design and employer election.

Coverage Limits
Authorization periods, quantity limits, cost sharing, and continuation requirements vary by plan. Ongoing clinical review may be required to maintain coverage. 

Carrier Resources
GLP-1 Benefit Coverage Resource: Employer overview explaining customization options, prior authorization, formulary strategies, and weight-management support programs.
Customizable Weight Management Solutions: Content around balancing coverage, cost, and care.

Anthem Blue Cross

Coverage Available?
Yes, depending on the employer's pharmacy plan and benefit structure. 

Qualification Requirements
Coverage generally requires prior authorization and clinical review. Requirements may vary based on the diagnosis, approved indication, and specific plan.

What's Covered?
Employer plans that include obesity treatment coverage may provide access to medications such as Wegovy®, Zepbound®, and Saxenda®.

Coverage Limits
Coverage levels, member cost sharing, and utilization management requirements depend on the employer's selected benefits and formulary.

Carrier Resources
Anthem Drug List: The medications on the drug list are chosen based on a number of factors including how well they work, value to patients and safety. All drugs on these lists are approved by the Food and Drug Administration (FDA).

Blue Shield of California

Coverage Available?
Yes, although coverage varies by employer segment and pharmacy formulary.

Qualification Requirements
Members typically must meet medical necessity and prior authorization requirements established by Blue Shield's pharmacy policies.

What's Covered?
Covered medications depend on the employer's formulary, but approved anti-obesity medications may be available when included within the pharmacy benefit.

Coverage Limits
Cost share, tier placement, authorization requirements, and formulary status vary by employer group and are updated periodically. 

Carrier Resources
Weight Management Agents Drug Policy: Covers common questions around BMI requirements, prior authorization, lifestyle program participation, reauthorization requirements, and coverage duration. 
Group Broker Update on GLP-1 Drugs: Explanation of coverage considerations, prior authorization, and the role of lifestyle modification.

Health Net

Coverage Available?
Yes. Health Net provides published California employer-group criteria specific to weight-loss medications.

Qualification Requirements
Coverage generally requires prior authorization and participation in a structured weight-management program that incorporates diet, physical activity, and behavioral modification components.

What's Covered?
Health Net identifies Wegovy®, Zepbound®, Saxenda®, Qsymia®, Contrave®, and Xenical® among its covered weight-management medications when eligibility requirements are met.

Coverage Limits
Coverage remains subject to employer plan design and ongoing program participation requirements. Prior authorization continues to play a central role in maintaining eligibility.

Carrier Resources
Weight Loss Medications Coverage Criteria: New requirements and eligibility guidelines apply to members on select Health Net plans
Health Net Pharmacy Information: Quick access to drug lists and pharmacy forms. You can find the most current information on drug coverage for both Medicare and commercial plans.

Kaiser Permanente

Coverage Available?
Yes, for qualifying members under Kaiser clinical guidelines.

Qualification Requirements
Coverage is based on medical necessity, physician oversight, and Kaiser-specific clinical criteria. Program participation may also be part of the evaluation process.

What's Covered?
Coverage depends on the employer's Kaiser plan and formulary design.

Coverage Limits
Access, duration, and ongoing eligibility requirements vary based on Kaiser clinical policies and employer benefits.

Carrier Resources
What you need to know about GLP-1s: This includes why you take it, how to take it, what you can expect while you're taking it, and any warnings about the medicine. The information provided here is general. 

UnitedHealthcare

Coverage Available?
Yes, depending on employer elections and pharmacy benefit configuration.

Qualification Requirements
Members generally undergo prior authorization and clinical review to confirm medical necessity and treatment appropriateness.

What's Covered?
Employer plans that include obesity-management benefits may cover FDA-approved anti-obesity GLP-1 medications.

Coverage Limits
Coverage commonly includes utilization management controls and periodic reassessment of treatment effectiveness.

Carrier Resources
Weight Loss Medication Prior Authorization Program: Details weight-loss coverage criteria, prior authorization requirements, BMI considerations, and employer-specific plan design impacts. 
Employer Considerations for GLP-1 Coverage: Reviews emerging GLP-1 utilization trends, employer cost considerations, and strategies for integrating weight management programs.

Sharp Health Plan

Coverage Available?
Potentially, depending on medical necessity and employer benefit design.

Qualification Requirements
Prior authorization and clinical review are typically required before coverage is approved.

What's Covered?
Coverage depends on the applicable formulary and employer-selected pharmacy benefits.

Coverage Limits
Plan-specific coverage limits, cost sharing, and authorization requirements apply.

More questions about GLP-1 coverage? Contact Your Dickerson Sales Representative for more information.