Cigna prior authorization for Ozempic, Wegovy, Mounjaro & Zepbound

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 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—drugs used in the management of Type 2 diabetes as well as conditions relating to obesity (including weight loss). 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 are likely to be covered for weight loss, but they could both be covered for Type 2 diabetes. Wegovy and Zepbound could both be covered for the treatment of weight loss 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.”  

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 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). 

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.

How to get prior authorization for Ozempic

To be approved for coverage for Ozempic, Cigna requires that the drug be prescribed for Type 2 diabetes. It’s 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 to obtain prior authorization for Ozempic, depending on your medical history. Cigna allows Ozempic to be prescribed as a first-line treatment for Type 2 diabetes if you have cardiovascular (CV) disease or are at high risk for CV disease. If you don’t have CV disease or risk factors for CV disease, Cigna typically requires prior authorization for Ozempic since metformin is the preferred treatment for Type 2 diabetes. However, if treatment with metformin fails and Ozempic is allowed under your specific Cigna plan, your healthcare provider can make the request for prior authorization.

RELATED: Ozempic vs. metformin: Differences, similarities, and which one is better for you

How to get prior authorization for Wegovy

Wegovy is approved for the use of chronic weight management under some Cigna plans, though prior authorization is required. Medical necessity is also 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 CV disease

Your healthcare provider will assist you with obtaining prior authorization for Wegovy if you meet the criteria.

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 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.

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:

1. Stay informed about your insurance plan’s formulary and coverage policies so you can anticipate prior authorization requirements. 
2. Maintain open communication with your healthcare provider, providing them with updated insurance information. 
3. Make sure your healthcare provider has all the medical documentation necessary to submit a prior authorization request to your insurance provider. 
4. 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.

Finally, you can use a SingleCare prescription discount card 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.