The two tests, kept separate
Test 1 — clinical eligibility
Can a clinician appropriately prescribe this to you? Decided by the FDA-approved population, your diagnosis, your other conditions, and the contraindications. This is a medical judgement made by a person who has assessed you.
Test 2 — coverage eligibility
Will your plan pay? Decided by the plan's own criteria, which sit on top of the clinical ones and are frequently stricter — and by whether your employer bought the benefit at all. This is a contractual question, not a medical one.
Keeping them apart matters because the remedies differ. Failing the clinical test means the drug may not be right for you. Failing the coverage test means the drug may be right for you and someone else has decided not to pay — which is arguable, or not, depending on which kind of no you got.
Clinical criteria by drug
| Drug | Approved population | Second route |
|---|---|---|
| Wegovy | Chronic weight management — generally BMI 30+, or 27+ with a weight-related condition | Cardiovascular risk reduction with established heart disease |
| Zepbound | Chronic weight management — same BMI framing | Moderate-to-severe obstructive sleep apnea in obesity |
| Ozempic | Type 2 diabetes | Cardiovascular risk reduction in T2D with heart disease |
| Mounjaro | Type 2 diabetes | — |
The right-hand column is worth noticing: those second indications are not weight-loss uses, which means they can qualify someone whose plan excludes weight-loss medication entirely. Whether one applies depends on your documented diagnosis.
The baseline-weight trap
Plans typically want your baseline weight and BMI — the starting figures. If you lost weight on your own before asking, your current BMI may sit below the threshold while your documented baseline still qualifies you. That figure has to be in your chart, and it is the single most common reason a request from an otherwise-eligible person fails.
The practical move: before a prior authorization is submitted, ask the prescriber's office to confirm the chart contains a baseline weight and BMI with a date, not just your most recent reading.
Who should not take one
Class-wide contraindications from the labels. This is what to raise before a prescriber decides — not a self-screening tool.
- A personal or family history of medullary thyroid carcinoma — and people frequently do not know this applies until asked directly about relatives.
- Multiple endocrine neoplasia syndrome type 2 (MEN 2).
- Pregnancy, or planning one. The semaglutide label advises stopping at least about two months before a planned pregnancy. This matters more than people expect: these drugs can restore ovulation, and therefore fertility.
- Prior serious hypersensitivity to the drug or its components.
- A history of pancreatitis is not an absolute bar on every label, but is an explicit conversation rather than an assumption.
What plans add on top
Coverage criteria sit above the clinical ones. The common pattern across major pharmacy benefit managers:
- The BMI threshold, documented at baseline.
- A documented lifestyle intervention, frequently around three months, recorded with dates rather than described.
- Step therapy in some plans — trying another agent first, or documenting why you cannot.
- Response for reauthorization — commonly at least 5% weight loss to continue.
- For diabetes brands, a documented type 2 diabetes diagnosis; an off-label weight-loss request will generally be denied.
Full criteria: GLP-1 prior authorization · coverage and appeals
The documentation that decides it
Baseline weight and BMI
With a date. The starting figures, not the most recent ones.
Diagnosis codes
For obesity and every qualifying comorbidity. A condition that is true but uncoded does not count.
Prior therapy with dates
Drug names, doses, how long, and why each stopped. "Tried and failed" without dates is not documentation.
Documented intolerance
Recorded when it happened, not recalled afterwards.
Lifestyle-intervention records
If your plan requires a supervised program.
Confirming these are in the chart before submission is worth more than any appeal written afterwards, because most first denials are gaps in this list rather than genuine ineligibility.
Where the answer is honestly no
Two situations worth stating plainly rather than dancing around.
Cosmetic weight loss. These drugs are approved for chronic weight management in a defined population. Wanting to lose fifteen pounds does not put you in it, insurance will not cover it, and a legitimate clinician will say so. A provider willing to prescribe without a real assessment is a warning sign about that provider, not a shortcut.
Adolescents. Some GLP-1s carry adolescent indications with their own criteria, but this involves growth, development and long-term treatment questions that do not apply to adults. It belongs with a paediatric clinician, not a general telehealth intake.
Educational information reviewed 2026-07-20, not medical advice. Eligibility is a decision for a licensed clinician who has assessed you — this page describes the criteria so you know what to bring to that conversation.