Weight Loss Drugs (GLP-1) Coverage
GLP-1 medications, also known as glucagon-like peptide-1 receptor agonists (GLP-1Ras), mimic the hormone GLP-1 in the body. This hormone helps control blood glucose levels, insulin production, and feelings of fullness. GLP-1 medications treat type 2 diabetes and assist in weight management.
The guidelines for weight loss drugs are continually being updated.
Updated 01/27/2026.
Aetna/Aetna Funding Advantage
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Yes
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
GLP-1 Coverage Details and Criteria:
Clinical criteria can be found on the Aetna public site for providers, health care professionals also may obtain information by calling the Pharmacy Management Precertification Unit at 1-800-414-2386, or they can register to use the password-protected provider website. Visit www.aetna.com, select "Doctors & Hospitals" and choose "Physician Self-Service." Once registration is completed, healthcare professionals may use our online Precertification/medical exception email request form.
Clinical Policy Bulletins on the public provider site here, can be shared with members/providers for criteria. The bottom of the page has a “Pharmacy Criteria” search box.
Are there coverage limits (e.g., 6 months, one year, etc.)?
Because coverage approval can vary depending on the member's plan, please direct members to the CPB link and their specific plan benefits to check if coverage is approved. The Clinical Policy Bulletins available on the public provider site can be shared with members and providers for reference on eligibility criteria. At the bottom of the page, there is a “Pharmacy Criteria” search box that can be utilized.
Is the coverage full or is it at 50%?
Because coverage approval can vary depending on the member's plan, please direct members to the CPB link and their specific plan benefits to check if coverage is approved. The Clinical Policy Bulletins available on the public provider site can be shared with members and providers for reference on eligibility criteria. At the bottom of the page, there is a “Pharmacy Criteria” search box that can be utilized
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Because coverage approval can vary depending on the member's plan, please direct members to the CPB link and their specific plan benefits to check if coverage is approved. The Clinical Policy Bulletins available on the public provider site can be shared with members and providers for reference on eligibility criteria. At the bottom of the page, there is a “Pharmacy Criteria” search box that can be utilized.
Supporting Collateral:
Middle Market Formulary: The formularies indicate which brands are covered, the pharmacy tier, and if step therapy/prior authorization is required. Find a Medication: Prescription Drug List (Formulary), Coverage & Costs | Aetna
Middle Market (Fully Insured) – Advanced Control Plan – California
Middle Market and Small Group (AFA) - Advanced Control Plan
Small Group Formulary:
For the AFA small group level-funded plans, coverage for weight loss medications is excluded.
On the CA ACA plans the following applies:
There are two separate formularies, one for HMO and one for PPO.
2025 Formulary links:
Covered Medications:
Here are the 2025 ACA PPO formulary medications for this class (found HERE):
The HMO formulary includes the following:
Trulicity – Tier 2 (page 79), ST/Ql
Victoza – Tier 3 (page 79), ST/Ql
Xultophy - Tier 3 (page 80), ST
Anthem Blue Cross
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Yes
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
Yes.
When prescribed solely to lose weight, except for the Medically Necessary treatment of morbid obesity. Members who are prescribed weight loss drugs that are Medically Necessary for the treatment of morbid obesity may be required to enroll in a comprehensive weight loss program, which is approved and covered by the Plan, for a reasonable period before or concurrent with receiving the Prescription Drug.
Are there coverage limits (e.g., 6 months, one year, etc.)?
Yes.
Members who are prescribed weight loss drugs that are Medically Necessary for the treatment of morbid obesity may be required to enroll in a comprehensive weight loss program, which is approved and covered by the Plan, for a reasonable period before or concurrent with receiving the Prescription Drug.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Yes.
Members who are prescribed weight loss drugs that are Medically Necessary for the treatment of morbid obesity may be required to enroll in a comprehensive weight loss program, which is approved and covered by the Plan.
Supporting Collateral:
Covered Medications:
Ozempic, Trulicity, and Victoza - tier 2 but needs prior authorization.
Trulicity and Bydureon - non-formulary. Needs prior authorization.
Mounjaro is non-formulary/specialty- it needs prior authorization.
Wegovy is non-formulary; it will need prior authorization. This drug was recently approved for Cardiovascular risk reduction.
Zepbound is non-formulary and will require PA. This is the drug that might be the hardest to approve since it is only approved for weight loss.
Health Net
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Yes. All weight loss drugs require prior approval based on Health Net’s drug use guidelines
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?
For approval, Health Net Medical Necessity criteria must be met based on:
BMI (Body Mass Index)
Documentation of member’s baseline and current height and body weight within the last 30 days
Other medical issues
Documentation supporting member’s participation in a Health Net-approved weight loss program (e.g., Weight Watchers) or other weight loss programs recommended by the prescriber that involves:
a reduced calorie diet
increased physical activity and
behavioral modification.
Are there coverage limits (e.g., 6 months, one year, etc.)?
No, however, Health Net will requalify.
Is the coverage full or is it at 50%?
Benefits will depend on the plan enrolled on.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Yes, documentation supporting member’s participation in a Health Net-approved weight loss program (e.g., Weight Watchers) or other weight loss programs recommended by the prescriber that involves:
a reduced calorie diet
increased physical activity and behavioral modification.
Supporting Collateral:
To request prior authorization, the prescriber must complete and fax a Prior Authorization form (PDF) to 866-399-0929.
To access Pharmacy Prior Authorization Guidelines, please refer to:
Health Net Commercial Drug Coverage Policies | Health NetTo access the List of Covered Drugs based on your group size, please refer to:
Employer Group Drug List | Health NetCovered Medications:
Ozempic Self-injection dosing once a week
OZEMPIC® is a glucagon-like peptide 1 (GLP-1) receptor agonist indicated as: • an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. To reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease.
Weight Loss – Not Covered coverage requires prior authorization. Based on BMI and other medical conditions
Saxenda (self-injected medication dosing is daily)
SAXENDA® is a glucagon−like peptide−1 (GLP−1) receptor agonist indicated:
• as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management.
• to reduce the risk of major adverse cardiovascular events in adults with type 2 diabetes mellitus and established cardiovascular disease.
Requires 6 months participation in a lifestyle modification / weight loss program that includes a lifestyle program, a reduced calorie diet and increased physical activity before requesting prior authorization.Adult patients with an initial body mass index (BMI) of:
30 Kg/m2 or greater or
27Kg/m2 or greater in the presence of at least one weight-related medical condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia
Weight Loss – is Covered. Coverage Requires prior authorization. Based on BMI and other medical conditions
Wegovy (self-injected medication dosing is weekly)
WEGOVY® is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated in combination with a reduced calorie diet and increased physical activity:
• to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with established cardiovascular disease and either obesity or overweight.
• to reduce excess body weight and maintain weight reduction long term in: • Adults and pediatric patients aged 12 years and older with obesity
• Adults with overweight in the presence of at least one weight-related comorbid condition. Requires 6 months participation in a lifestyle modification /weight loss program that includes a lifestyle changes, a reduced calorie diet and increased physical activity before requesting prior authorization.Adult patients with an initial body mass index (BMI) of:
30 Kg/m2 or greater or
27Kg/m2 or greater in the presence of at least one weight-related medical condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia
Weight loss is covered. Coverage Requires prior authorization. Based on BMI and other medical conditions.
Zepbound (self-injected medication dosing is weekly)
ZEPBOUND® is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist indicated in combination with a reduced-calorie diet and increased physical activity:
to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition.
to treat moderate to severe obstructive sleep apnea (OSA) in adults with obesity.
Requires 6 months participation in a lifestyle modification /weight loss program that includes a lifestyle changes, a reduced calorie diet and increased physical activity before requesting prior authorization.
Adult patients with an initial body mass index (BMI) of:
30 Kg/m2 or greater or
27Kg/m2 or greater in the presence of at least one weight-related medical condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)
Weight loss is covered. Coverage Requires prior authorization. Based on BMI and other medical conditions
Mounjaro dosing is weekly
MOUNJARO® is a glucose-dependent insulinotropic polypeptide (GIP) receptor and glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
Weight loss is not covered
UnitedHealthcare
Do your plans cover Weight Loss Drugs (GLP-1) if deemed medically necessary? If so, how are they covered?
Covered for CA small business fully insured plans.
Are there any clinical criteria for approval (e.g., BMI level, sustained weight min/max, step therapy such as a weight loss management program)?Are there coverage limits (e.g., 6 months, one year, etc.)?
(BMI) of greater than or equal to 30 kg/m2 or 27 kg/m2 with an obesity-related comorbidity.
Motivation-based wellness program participation and prior authorization are required before drug coverage.
Are there coverage limits (e.g., 6 months, one year, etc.)?
No, limitations are noted currently, but Prior Authorization and Supply Limits apply.
Is the coverage full or is it at 50%?
GPL-1 covered medications in the PDL, cost-share applies based on Tier and the member’s Rx plan benefit.
Do members need to be enrolled in a comprehensive weight loss program before or concurrently receiving the weight loss drug?
Motivation-based wellness program participation and prior authorization are required before drug coverage.
Supporting Collateral:
N/A
Covered Medications:
Please refer to the CA SB PDL lists for the GLP-1 medications covered. They all fall under Tier 3 of the member’s Rx plan benefit.
NOTED:PA (prior authorization required)
M (may be covered under the medical benefit with prior authorization for HMO plans
SL (supply limits) as outlined in the PDL