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Key takeaways
Prior authorization is often required by insurance companies to confirm that a prescription or service is medically necessary. If your request is approved, your out-of-pocket cost depends on the details of your plan.
Cigna typically requires prior authorization for all GLP-1 agonist drugs, including Ozempic, Wegovy, Mounjaro, and Zepbound, regardless of the indication they’re prescribed for.
If you don’t have any insurance coverage for your GLP-1 drug through Cigna, consider using a SingleCare prescription discount card to save money.
Prior authorization is a common part of the process of receiving coverage for a prescription drug through your insurance provider. While drugs on your plan’s formulary, or list of preferred medications, don’t always require prior authorization, many drugs do need to be reviewed by your health insurance company for medical necessity before they cover them.
All insurance companies have their own set of criteria that determine which drugs they cover and at what cost to the patient. Many companies require prior authorization for glucagon-like peptide-1 (GLP-1) receptor agonists and GIP/GLP-1 agonists (often referred to together as GLP-1s in insurance coverage policies)—drugs used in the management of Type 2 diabetes as well as weight loss and long-term weight management. Cigna insurance plans are no different. Here, we’ll be reviewing Cigna’s coverage for the GLP-1 agonists Ozempic (semaglutide), Wegovy (semaglutide), Mounjaro (tirzepatide), and Zepbound (tirzepatide), including whether prior authorization is needed for coverage and, if so, how to get it.
Cigna coverage criteria for GLP-1 drugs
Cigna generally only covers GLP-1 drugs when they are prescribed for a diagnosis that matches what the Food and Drug Administration (FDA) approved them for. In other words, neither Ozempic nor Mounjaro is likely to be covered for weight loss, but they could both be covered for Type 2 diabetes, because they are FDA approved for that use. Wegovy and Zepbound could both be covered for the treatment of weight loss (an FDA-approved use) but would not be approved for use in treating Type 2 diabetes.
Related: Mounjaro vs. Ozempic: Differences, similarities, and side effects
But your plan benefits dictate much of the coverage as well. Any coverage you receive for a GLP-1 agonist depends completely on your specific Cigna plan, according to Roy Moore, senior healthcare research and data analyst at Clarivate, an information services agency.
Cigna prior authorization for weight-loss drugs
“Cigna typically requires prior authorization for all types of weight loss drugs, including GLP-1 agonists,” says Moore. “However, the prior authorization criteria for drugs on its national formulary are somewhat flexible,” Moore noted. “Patients often receive prior authorization approval but typically need to have tried other strategies, like behavioral and dietary changes, for at least three months before coverage is approved.”
RELATED: Can I take Ozempic if I’m not diabetic?
Cigna prior authorization for GLP-1 drugs
Just like other forms of weight loss drugs (such as Contrave, Qsymia, or phentermine), Cigna has policies that outline its prior authorization process for GLP-1 agonists. In general, prior authorization can be obtained for some of the GLP-1 agonists if you and your healthcare provider can prove they are medically necessary and you meet certain criteria. But approval is usually only granted if you’re being prescribed the drug for one of its FDA-approved indications (e.g., Type 2 diabetes versus weight loss, depending on the specific drug).
For weight-loss drugs like Wegovy or Zepbound, Cigna may also require additional information for continued coverage. For example, your healthcare provider may need to document that you have lost at least 5% of your baseline body weight after one year.
In general, Cigna requires healthcare providers to request and obtain prior authorization (also called precertification) for in-network services. As the patient, you shouldn’t have to do much in order to initiate or complete the request.
Cigna prior authorization for GLP-1 drugs: Comparison chart |
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|---|---|---|---|
| Drug | Indication | Covered? | Coverage requirements |
| Ozempic | For adults with type 2 diabetes mellitus | Yes (may require prior authorization) | Must have a diagnosis of Type 2 diabetes and be 18 years of age or older. May also be covered for other FDA-approved uses of cardiovascular risk reduction or chronic kidney disease if conditions are met. |
| Wegovy | For the treatment of obesity in adults and pediatric patients ages 12 and older; or adults with overweight with at least one weight-related health condition | Yes (requires prior authorization) | Must have engaged in behavioral modification and dietary restriction for at least three months
Adults must have an initial body mass index (BMI) of 30 or higher or an initial BMI of 27 or higher (overweight) with at least one weight-related health condition Pediatric patients 12 and older must have an initial BMI at the 95th percentile or higher for age and sex May also be covered for other FDA-approved uses of cardiovascular risk reduction or MASH, if conditions are met |
| Mounjaro | For adults with Type 2 diabetes | Yes (requires prior authorization) | Must have a diagnosis of Type 2 diabetes and be 18 years or older |
| Zepbound | For the treatment of obesity and overweight in adults | Yes (requires prior authorization) | Must be 18 years or older and must have engaged in behavioral modification and dietary restriction for at least three months
Must have an initial BMI of 30 or higher or an initial BMI of 27 or higher (overweight) with at least one weight-related health condition May also be covered for other FDA-approved use of moderate to severe obstructive sleep apnea in adults with obesity, if conditions are met |
How to get prior authorization for Ozempic
Ozempic is FDA approved for Type 2 diabetes—as well as cardiovascular risk reduction and chronic kidney disease in adults with Type 2 diabetes. Cigna may cover Ozempic for these FDA-approved uses, but coverage varies by plan, and prior authorization is often needed. Ozempic is not approved for use as a weight loss treatment, for diabetes prevention, or to treat Type 1 diabetes or metabolic syndrome (without a co-diagnosis of Type 2 diabetes).
You may or may not need prior authorization for Ozempic, depending on your plan. Clinical guidelines recommend Ozempic as a first-line treatment for people with Type 2 diabetes who also have cardiovascular disease or are at high risk for it. Cigna may cover Ozempic in these cases, but prior authorization is typically still required.
If you don’t have cardiovascular disease or risk factors for cardiovascular disease, metformin is often used first. But if metformin alone is not effective, your Cigna plan may cover Ozempic with a prior authorization.
RELATED: Ozempic vs. metformin: Differences, similarities, and which one is better for you
How to get prior authorization for Wegovy
Wegovy is FDA approved for chronic weight management and may be covered under some Cigna plans, though prior authorization is required. Your healthcare provider will have to inform Cigna that you have performed behavioral modifications (e.g., increasing exercise) and a reduced-calorie diet for at least three months, and have either:
- A BMI of 30 or higher, or
- A BMI of 27 or higher, plus a weight-related comorbidity approved by Cigna, such as hypertension, Type 2 diabetes, dyslipidemia (high cholesterol), obstructive sleep apnea, or cardiovascular disease
Wegovy is also FDA approved for cardiovascular risk reduction. Your healthcare provider will assist you with obtaining prior authorization for Wegovy if you meet the criteria.
Wegovy was also recently approved to treat noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH) with moderate to advanced liver fibrosis in adults. However, information is not yet available regarding coverage. It is likely that Cigna would cover Wegovy for this use with a prior authorization, but it’s best to check with your specific plan to be sure.
How to get prior authorization for Mounjaro
Just like it does with Ozempic, Cigna requires that Mounjaro be prescribed for Type 2 diabetes, not for weight loss, Type 1 diabetes, diabetes prevention, or metabolic syndrome (without a co-diagnosis of Type 2 diabetes). However, unlike Ozempic, Mounjaro typically always requires prior authorization for coverage.
How to get prior authorization for Zepbound
The Cigna coverage and prior authorization requirements for Zepbound for weight loss are the same as they are for Wegovy. If it’s covered under your plan benefits and your provider decides Zepbound is the right fit for you, they will process the request for prior authorization. Zepbound is also FDA approved for obstructive sleep apnea in adults with obesity. Coverage for this use may vary by plan, and prior authorization is required.
Prior authorization tips
Hearing that you’ll need to obtain prior authorization for your prescription to be covered can be intimidating, but it doesn’t have to be. Yoshua Quinones, MD, an internist with Medical Offices of Manhattan and contributor to LabFinder, says there are a few things you can do as a patient to make the process easier:
- Stay informed about your insurance plan’s formulary and coverage policies so you can anticipate prior authorization requirements.
- Maintain open communication with your healthcare provider, providing them with updated insurance information.
- Make sure your healthcare provider has all the medical documentation necessary to submit a prior authorization request to your insurance provider.
- Follow up on prior authorization requests and advocate for yourself, if needed, but also remember to be patient. Provider offices are busy and often handle many of these requests for patients at one time. In the meantime, explore alternative medication options with your provider in case your request isn’t approved.
RELATED: Mounjaro (tirzepatide) alternatives: What can I take instead of Mounjaro?
How to save on weight-loss drugs
If your Cigna plan doesn’t cover your weight loss medication, Dr. Quinones says healthcare providers can usually swap one GLP-1 medication out for another if there are no other contraindications or issues with your medical history. Ask your healthcare provider if they have any other recommendations that may be covered.
If not, there are still ways to save money on your prescription. In addition to copay cards for qualifying patients—which often allow you to get a drug at little or no out-of-pocket cost, many drug manufacturers have patient assistance programs to support people who can’t otherwise pay for their medications. You can check the manufacturer websites for more information on savings—Eli Lilly for Mounjaro and Zepbound, and Novo Nordisk for Ozempic and Wegovy.
Finally, you can use a SingleCare discount to save money on weight loss drugs, including GLP-1 agonists. The discount card allows you to apply SingleCare coupons to the pharmacies in your area so you can shop for the lowest available price.