in 22 days NovoCare Pharmacy self-pay — Wegovy® tablets (oral semaglutide) 4 mg moves to $199/month See the changelog
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Kaiser Permanente

Integrated system (regional formularies) · updated August 8, 2026

Coverage right now

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.

Drug status

DrugStatusDetailConfidence
Wegovy® (semaglutide injection)Varies
from Jan 1, 2025
NW: covered only with weight-loss drug benefit + PA + heavy step. CA (NCAL/SCAL): removed from base commercial for BMI < 40 eff 1/1/2025. WA: excluded on most 2026 formularies. Mid-Atlantic: PA per 2024 form criteria. sourcehigh
Zepbound® (tirzepatide)Varies
from Jun 18, 2026
NW: covered with benefit + PA, last-line after two orals AND >= 6-month semaglutide trial (criteria rev 6/11/2026, eff 6/18/2026). sourcehigh
Wegovy® tablets (oral semaglutide)Unknown Not found in retrieved KP formularies/criteria as of Aug 2026 — KP regions typically slow-add. sourcelow
Foundayo™ (orforglipron)Unknown Not found in retrieved KP documents; members cited ~$149/month cash option instead. sourcelow
Saxenda® (liraglutide)Varies Mid-Atlantic PA form pairs Wegovy/Saxenda; WA lists generic liraglutide Tier 1 PA/QL. sourcehigh
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 in all regions where a weight-loss drug benefit exists.
Initial BMI
NW: BMI >= 30, or >= 27 with comorbidity. MAS: BMI >= 30 or 27-<30 with >= 1 condition. CA base plans: effectively BMI >= 40 since 1/1/2025.
Comorbidities
NW (broad list): HTN, diabetes, hyperlipidemia, pre-diabetes, established CVD/stroke, CHF, CKD, NAFLD, OSA, weight-bearing osteoarthritis, PCOS.
Lifestyle requirement
NW: actively making lifestyle modification or active behavioral-health referral. MAS: enrollment in a program (KP DPP, Weight Watchers, Noom, etc.).
Initial authorization
NW 12 · MAS 6
Reauthorization
NW: achieved and maintained >= 5% weight loss (12-month cycles). MAS: >= 5% from baseline documented within previous 3 months.
Step therapy
STRICTEST OF ANY MAJOR PAYER. NW Wegovy: fail adequate 3-month trials of >= 2 of phentermine/diethylpropion/topiramate/Qsymia/Contrave, then fail semaglutide (Ozempic). NW Zepbound: the two-oral step PLUS a failed minimum 6-month semaglutide trial. MAS: phentermine, topiramate, naltrexone, bupropion, Wegovy, orlistat trials.
Quantity limits
QLs flagged; counts not enumerated in public PDFs.

Primary criteria document:healthy.kaiserpermanente.org

Exceptions and appeals

Appeal deadline
60 days
Deadline detail
60 days from denial for internal appeal (member process); CA IMR after internal exhaustion (immediate if imminent threat).
Exception route
MAS: fax PA form 1-866-331-2104. All regions: kp.org portal/phone grievance-appeal. CA members: DMHC Independent Medical Review after internal exhaustion, 1-888-466-2219 — binding on KP.
Turnaround
MAS PA form: 24-hour fax turnaround. Internal appeal: 30 days standard / 72h expedited. DMHC IMR ~30 days / 72h expedited.
Where
Region-specific — via kp.org.

Source:findhonestcare.com

Dated changes

  • Jan 1, 2025 CA base commercial plans removed Wegovy for BMI < 40 source
  • Jan 1, 2026 Medi-Cal carve-out ended weight-loss GLP-1s for KP Medi-Cal members (state action) source
  • Jun 18, 2026 NW Zepbound criteria re-issued, keeping the 6-month semaglutide-first step source
Regions: NCAL, SCAL, CO, GA, HI, MAS (MD/DC/VA), NW (OR/SW WA), WA. CO/GA/HI statuses unverified (no regional documents surfaced). For CA members the DMHC Independent Medical Review is the most powerful lever — external, binding, and free.
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.