Prior authorization is where most insured people meet the GLP-1 system, and it is usually described in the vaguest possible terms: "you'll need to meet your plan's criteria". The criteria are not secret. Some insurers publish them. This page reads Aetna's published pharmacy policies for Wegovy and Zepbound line by line and sets each requirement against what the FDA label actually says, as of 28 September 2026. Aetna's criteria are one insurer's, used here because they are public and specific; other plans differ.
Who pays at all — Medicare, Medicaid, employer plans — is on GLP-1 insurance coverage. Medicare's temporary $50 programme, which has its own prior authorization, is on the Medicare GLP-1 Bridge.
The label versus the policy
| Requirement | FDA label (Wegovy, Zepbound) | Aetna policy (Wegovy 4774-C, Zepbound 6192-C) |
|---|---|---|
| Adult BMI ≥30, or ≥27 with a weight-related condition | yes — the indication | yes, with documentation |
| Used with reduced-calorie diet and more activity | yes | yes |
| Six months in a weight-management programme before the drug | no | yes ("with continuing follow-up for at least 6 months prior to using drug therapy") |
| 5% weight loss to keep coverage | no (Wegovy and Zepbound have no stop rule) | yes, after ≥3 months at a stable maintenance dose |
| Approval length | — | Wegovy 7 months, Zepbound 8 months initial; 12 months on renewal |
| Quantity | label pens per month | one pack of 4 pens (or 4 vials) per 21 days; 3 packs per 63 days |
Three of those rows are added by the insurer, not taken from the label: the prior programme, the 5% renewal test and the time limit. That is the practical meaning of "criteria" — and the most common reason a request stalls is a missing document for one of them rather than a patient being outside the label.
The six-month programme
The policy asks that the patient "has participated in a comprehensive weight management program that encourages behavioral modification, reduced calorie diet, and increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy." Neither label contains a waiting period; both simply say the drug is used alongside diet and activity. What counts as a "program" is not defined further in the policy text — which is why documentation of supervised visits matters in practice.
The 5% test at renewal
To continue, the patient must have "completed at least 3 months of therapy with the requested drug at a stable maintenance dose" and "lost at least 5 percent of baseline body weight OR … continued to maintain their initial 5 percent weight loss."
This mirrors a stop rule that exists on some other weight-loss labels — Saxenda, Contrave and Qsymia — but not on Wegovy or Zepbound (see how long GLP-1 takes to work). The timing matters: the Wegovy label escalates over 16 weeks and Zepbound's over at least 20 before the top dose, so "three months at a stable maintenance dose" typically means the check lands seven to eight months after starting — which is where both initial approvals expire. The schedules are on GLP-1 titration schedules.
The Zepbound policy adds a note that for a patient "transitioning from another drug therapy for weight loss", the baseline BMI is the one "at the start of any drug therapy" — so someone who has already lost weight on another drug is not penalised for it.
The heart path is different
Wegovy's second label indication is reducing heart attacks, strokes and cardiovascular death in adults with established heart disease and obesity or overweight (from the SELECT trial). Aetna's policy gives that indication its own path:
- documented prior heart attack, stroke, symptomatic peripheral artery disease or revascularisation;
- BMI of 27 or more;
- no type 2 diabetes — the policy notes that Ozempic carries the cardiovascular indication for people with diabetes;
- current guideline-directed heart treatment, or a documented reason not to be on it;
- no 5% weight-loss test at renewal — only a maintenance dose.
The same drug, in the same plan, can therefore have two sets of renewal rules depending on which indication the prescriber submits.
Formulary moves and prior authorization
Prior authorization sits on top of the formulary: a drug has to be covered before an authorization means anything. The largest recent change: CVS Caremark removed Zepbound and preferred Wegovy on its commercial template formularies from 1 July 2025, and stated that "members with an active prior authorization for Zepbound will not need to obtain a new prior authorization if they move to Wegovy." Caremark announced on 28 May 2026 that Zepbound returns as an additional preferred option on 1 October 2026. The full record is on CVS Caremark and GLP-1s.
A plan can also exclude weight-loss drugs altogether. In that case there is no prior authorization to win — the exclusion is in the plan document, and it is the employer or plan sponsor's choice.
Medicare works differently
Traditional Part D plans are barred by statute from covering drugs used for weight loss alone, which is why Medicare coverage runs through other indications (heart disease, sleep apnoea, MASH) or the temporary Bridge. The Bridge's prior authorization, set by CMS rather than a private insurer, lasts through 31 December 2027, carries over dose changes, and needs renewing only if the patient switches drug — details on the Bridge page.
What this page cannot tell you
- Any particular plan's criteria. Employer plans can customise; the policy that binds is the one attached to the member's plan.
- Approval rates. No insurer publishes how many GLP-1 requests it approves or denies.
- Whether an appeal will succeed. Appeals and external reviews depend on the plan and the state.
This page reports published policy text; it is not advice on a specific claim or treatment. Decisions about whether a medicine is right belong with the prescriber. Cash-price routes for people without coverage are on cheapest GLP-1 without insurance.
Sources
- Aetna, Pharmacy Clinical Policy Bulletins, Non-Medicare Prescription Drug Plan: Wegovy PA with Limit 4774-C (UDR 08-2023 v2) and Zepbound PA with Limit 6192-C (P08-2024_R), both read 28 September 2026.
- WEGOVY prescribing information, Novo Nordisk, effective 2026-06-18 (DailyMed), sections 1 and 2; ZEPBOUND prescribing information, Eli Lilly, effective 2026-08-28, sections 1 and 2.
- CVS Health, "Improving access and affordability to high-cost weight management drugs", 27 June 2025, cvshealth.com.
- CVS Health, "CVS Caremark delivers affordability and access to GLP-1 weight management medications with expanded coverage options", 28 May 2026, cvshealth.com.