From the payers' own documents
Coverage policy, by payer
Prior-authorization criteria, step therapy, quantity limits, appeal routes and dated formulary changes — drawn from the payers' own published documents wherever they exist, with a confidence grade on everything else.
Aetna (CVS Health)
Insurer (Caremark-administered)
- Foundayo™ (orforglipron) Covered
- Wegovy® (semaglutide injection) Preferred
- Wegovy® tablets (oral semaglutide) Preferred
- Zepbound® (tirzepatide) Exception only
Criteria are essentially identical to the Caremark template (same BMI wording, 6-month program requirement, 5% reauth gate, same quantity limits). The difference is formulary architecture: standard Aetna commercial formularies made Zepbound exception-only after July 2025 with a step through Wegovy, while FE-compatible plans kept it PA-covered. Many Aetna plans exclude weight-loss drugs entirely (CPB 0039).
Blue Cross Blue Shield Federal Employee Program (FEP)
National uniform plan (published criteria)
- Foundayo™ (orforglipron) Unknown
- Saxenda® (liraglutide) Covered
- Wegovy® (semaglutide injection) Covered
- Wegovy® tablets (oral semaglutide) Covered
- Zepbound® (tirzepatide) Exception only
Restructured the class for 2026 citing GLP-1 cost growth: Zepbound moved to the Standard-option excluded list (obtainable only via formulary exception meeting policy 5.99.031, which adds a new two-oral-agents step plus preferred-product trial), while Wegovy and Saxenda held at Tier 3 with PA. Focus option does not cover anti-obesity drugs at all. One uniform national plan with genuinely published criteria — the most transparent payer in this corpus.
CVS Caremark
PBM standard commercial template
- Foundayo™ (orforglipron) Covered
- Saxenda® (liraglutide) Covered
- Wegovy® (semaglutide injection) Preferred
- Wegovy® tablets (oral semaglutide) Covered
- Zepbound® (tirzepatide) Excluded
Largest US PBM. Removed Zepbound from standard commercial template formularies July 1, 2025 (Wegovy preferred); returns Zepbound as an additional preferred option October 1, 2026 at ~$25/month for eligible commercial members. Template criteria — plan sponsors customize, and many employer plans exclude weight-loss drugs entirely.
Elevance Health / Anthem (CarelonRx)
Insurer + PBM
- Foundayo™ (orforglipron) Preferred
- Saxenda® (liraglutide) Non preferred
- Wegovy® (semaglutide injection) Preferred
- Wegovy® tablets (oral semaglutide) Preferred
- Zepbound® (tirzepatide) Preferred
The stable one: kept Wegovy AND Zepbound dual-preferred (Tier 2, PA/QL) through the 2025 upheavals, and added Foundayo fastest of the majors (May 15, 2026). Coverage still contingent on the employer including a weight-loss benefit. No single national criteria PDF — criteria served per-drug via the Anthem Drug List Search.
Express Scripts (Evernorth / Cigna)
PBM standard commercial template (National Preferred Formulary)
- Foundayo™ (orforglipron) Preferred
- Saxenda® (liraglutide) Non preferred
- Wegovy® (semaglutide injection) Preferred
- Wegovy® tablets (oral semaglutide) Preferred
- Zepbound® (tirzepatide) Preferred
Kept both Wegovy and Zepbound single-dose pens preferred through the 2025 upheaval. 2026 NPF: Zepbound pens, Wegovy (pens, HD, tablets), and Foundayo all preferred — but Zepbound KwikPens and vials are excluded (device-level steering). PA criteria run through the Cigna National Formulary policy cnf_684.
Humana
Medicare-focused (no employer commercial book)
- Foundayo™ (orforglipron) Excluded
- Saxenda® (liraglutide) Excluded
- Wegovy® (semaglutide injection) Excluded
- Zepbound® (tirzepatide) Excluded
Humana exited employer-group commercial medical (completed ~2024) — treat 'Humana commercial' as N/A; several consumer sites erroneously describe active plans. Its Part D formularies exclude weight-loss GLP-1s (statute), covering CV/MASH/OSA indications with PA on some formularies. Unusual dual role: Humana is CMS's central processor for the Medicare GLP-1 Bridge (BIN 028918, PCN MEDDGLP1BR), adjudicating $50 Bridge claims for all Medicare beneficiaries nationwide.
Kaiser Permanente
Integrated system (regional formularies)
- Foundayo™ (orforglipron) Unknown
- Saxenda® (liraglutide) Varies
- Wegovy® (semaglutide injection) Varies
- Wegovy® tablets (oral semaglutide) Unknown
- Zepbound® (tirzepatide) Varies
Regional variance is the defining feature, and Kaiser runs the strictest step therapy of any major payer: the NW region requires failing TWO oral weight-loss agents AND a 6-month semaglutide trial before Zepbound. California base commercial plans removed Wegovy for BMI < 40 effective 1/1/2025 (employer opt-in otherwise). Formulary exceptions are functionally in-house bariatric-medicine reviews.
Medicaid (state-by-state)
State programs + BALANCE model
- Wegovy® (semaglutide injection) Varies
- Zepbound® (tirzepatide) Varies
Coverage of GLP-1s for obesity is state-by-state: 13 states as of Jan 2026 (KFF count). Four states ELIMINATED coverage Jan 1, 2026 (CA, NH, PA, SC). The CMS BALANCE model lets states buy in at negotiated prices with rolling starts May 2026 - Jan 2027; the participating-state list was still unpublished as of Aug 8, 2026 (applications closed July 31).
Medicare (Part D + GLP-1 Bridge)
Federal program
- Foundayo™ (orforglipron) Covered
- Ozempic® (semaglutide) Covered
- Saxenda® (liraglutide) Excluded
- Wegovy® (semaglutide injection) Covered
- Wegovy® tablets (oral semaglutide) Covered
- Zepbound® (tirzepatide) Covered
Weight-loss-only GLP-1 use remains statutorily EXCLUDED from Part D (2003 MMA). The temporary Medicare GLP-1 Bridge (July 1, 2026 - Dec 31, 2027) fills the gap at a flat $50/month for Foundayo, Wegovy (all forms), and Zepbound KwikPen — running entirely outside the Part D plan. Diabetes (Ozempic/Mounjaro) and secondary indications (Zepbound-OSA, Wegovy-CV) route through standard Part D with PA.
Optum Rx (UnitedHealthcare)
PBM standard commercial template (Premium Standard Formulary)
- Foundayo™ (orforglipron) Unknown
- Saxenda® (liraglutide) Covered
- Wegovy® (semaglutide injection) Covered
- Wegovy® tablets (oral semaglutide) Covered
- Zepbound® (tirzepatide) Covered
Kept both Wegovy and Zepbound covered throughout 2025-2026 — no CVS-style exclusion — but both sit at Tier 3 (non-preferred brand) with PA + quantity limits. Weight-loss coverage is an opt-in employer benefit. Foundayo not yet listed as of the retrieved 2026 documents.
What these coverage words mean
Formulary vocabulary turns up on denial letters with no explanation. Here is what each term means on this site — including the two that describe a gap in our data rather than a decision by your plan.
- Preferred
- On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
- Covered
- On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
- Non preferred
- On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
- Exception only
- Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
- Excluded
- Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
- Varies
- The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
- Unknown
- Not yet verified against a primary document. Recorded as absent rather than guessed.
- N/A
- Not applicable to this payer.