Blue Cross Blue Shield Federal Employee Program (FEP)
National uniform plan (published criteria) · updated August 8, 2026
Coverage right now
- 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.
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Wegovy® (semaglutide injection) | Covered from Jan 1, 2026 | Tier 3 non-preferred with prior approval on Standard and Basic (inj + oral tabs incl. 25 mg). Not covered on Focus (exception -> Tier 2 cost share). source | high |
| Wegovy® tablets (oral semaglutide) | Covered from Jan 1, 2026 | Wegovy tablets (1.5/4/9/25 mg) Tier 3 PA on Basic; folded into the Wegovy formulary line. source | high |
| Zepbound® (tirzepatide) | Exception only from Jan 1, 2026 | On the 2026 FEP Blue Standard EXCLUDED DRUG LIST (alternatives: Wegovy, Saxenda, orals). Obtainable via formulary exception meeting policy 5.99.031; approved exceptions pay Tier 3 (Std/Basic) or Tier 2 (Focus). source | high |
| Foundayo™ (orforglipron) | Unknown | Not on 2026 FEP formulary documents as of Aug 2026; formulary-exception route available. source | medium |
| Saxenda® (liraglutide) | Covered from Jan 1, 2026 | Tier 3 PA on Standard/Basic; generic liraglutide Tier 1 PA on Basic. source | high |
What preferred, covered and exception only mean
- 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.
Prior authorization criteria
high- PA required
- Yes — prior approval on all covered anti-obesity meds; excluded GLP-1s need a formulary exception (which does not change out-of-pocket costs; tier exceptions not allowed).
- Initial BMI
- Adults 18+: BMI >= 30, OR >= 27 with established CVD or >= 1 weight-related comorbidity. Ages 12-17 (Wegovy/Saxenda): BMI >= 95th percentile.
- Comorbidities
- Type 2 diabetes, dyslipidemia, or hypertension; plus enumerated established-CVD conditions (CHD, prior MI/revascularization, cerebrovascular, PAD).
- Lifestyle requirement
- Participation in a comprehensive weight management program (e.g., Teladoc or another program) — required at initiation AND renewal.
- Initial authorization
- 6 (Wegovy/Saxenda/Zepbound; 12 for Wegovy-MASH); renewals 12.
- Reauthorization
- Lost at least 5% of baseline body weight OR maintained the initial 5% loss. Adolescents: maintained clinically significant weight loss.
- Step therapy
- NEW FOR 2026, Zepbound only: inadequate response or intolerance to TWO oral weight-management medications + trial of preferred products (Wegovy/Saxenda) unless valid medical exception. No dual GLP-1/AOM therapy.
- Quantity limits
- Wegovy 12 single-dose pens/84 days · Saxenda 15 pens/90 days · Zepbound 12 pens/84 days.
Primary criteria document:fepblue.org
Exceptions and appeals
- Appeal deadline
- See note
- Deadline detail
- FEHB disputed-claims process (not ERISA): written reconsideration to the carrier within 6 MONTHS of denial; carrier decides within 30 days; then OPM review within 90 days of the carrier's upholding letter; OPM decides ~60 days; then federal court only.
- Exception route
- Prescriber submits electronically, by fax, or mail using Caremark-hosted FEP forms. Phone 1-877-727-3784 (FEHB/PSHB) or 1-855-344-0930 (Medicare Rx).
- Turnaround
- Not published on the FAQ; secondary: ~72h standard / 24h urgent.
- Where
- Per FEP denial letter; OPM review per FEHB brochure Section 8.
Source:ghcscw.com
Dated changes
- Jan 1, 2026 Zepbound split into new policy 5.99.031 (two-oral + preferred-product step) and moved to the Standard excluded list; generic liraglutide added Tier 1; FEP cited 'rapid increase in the use of weight loss GLP-1s' as the cost driver source
FEHB appeals are NOT ERISA — different deadlines and an OPM review layer. Standard vs Basic: identical criteria and tier, different cost share. Several 2026 consumer sites misreport the Focus exception cost-share table; the official formulary book governs.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.