{"id":628032,"date":"2024-05-05T18:47:02","date_gmt":"2024-05-05T22:47:02","guid":{"rendered":"https:\/\/www.singlecare.com\/blog\/?p=628032"},"modified":"2025-09-11T15:52:46","modified_gmt":"2025-09-11T19:52:46","slug":"cigna-prior-authorization-weight-loss","status":"publish","type":"post","link":"https:\/\/www.singlecare.com\/blog\/cigna-prior-authorization-weight-loss\/","title":{"rendered":"Cigna prior authorization for Ozempic, Wegovy, Mounjaro & Zepbound"},"content":{"rendered":"

Prior authorization<\/span><\/a> is a common part of the process of receiving coverage for a prescription drug through your insurance provider. While drugs on your plan\u2019s <\/span>formulary<\/span><\/a>, or list of preferred medications, don\u2019t always require prior authorization, many drugs do need to be reviewed by your health insurance company for medical necessity before they cover them.\u00a0<\/span><\/p>\n

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 (<\/span>GLP-1<\/span><\/a>) receptor agonists and GIP\/GLP-1 agonists (often referred to together as GLP-1s in insurance coverage policies)\u2014drugs 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\u2019ll be reviewing Cigna\u2019s coverage for the GLP-1 agonists <\/span>Ozempic<\/span><\/a> (semaglutide), <\/span>Wegovy<\/span><\/a> (semaglutide), <\/span>Mounjaro<\/span><\/a> (tirzepatide), and <\/span>Zepbound<\/span><\/a> (tirzepatide), including whether prior authorization is needed for coverage and, if so, how to get it. <\/span><\/p>\n

Cigna coverage criteria for GLP-1 drugs\u00a0<\/span><\/h2>\n

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 <\/span>Ozempic nor Mounjaro<\/span><\/a> 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. <\/span>Wegovy and Zepbound<\/span><\/a> 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.\u00a0<\/span><\/p>\n

Related: Mounjaro vs. Ozempic: <\/b>Differences, similarities, and side effects<\/b><\/a><\/p>\n

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 <\/span>Roy Moore<\/span><\/a>, senior healthcare research and data analyst at Clarivate, an information services agency. <\/span><\/p>\n

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Cigna prior authorization for weight-loss drugs<\/span><\/h2>\n

\u201cCigna typically requires prior authorization for all types of weight loss drugs, including GLP-1 agonists,\u201d says Moore. \u201cHowever, the prior authorization criteria for drugs on its national formulary are somewhat flexible,\u201d Moore noted. \u201cPatients 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.\u201d\u00a0\u00a0<\/span><\/p>\n

RELATED: <\/b>Can I take Ozempic if I\u2019m not diabetic?<\/b><\/a><\/p>\n

Cigna prior authorization for GLP-1 drugs<\/span><\/h2>\n

Just like other forms of weight loss drugs (such as <\/span>Contrave<\/span><\/a>, <\/span>Qsymia<\/span><\/a>, or <\/span>phentermine<\/span><\/a>), 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\u2019re being prescribed the drug for one of its FDA-approved indications (e.g., Type 2 diabetes versus weight loss, depending on the specific drug).\u00a0<\/span><\/p>\n

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.<\/span><\/p>\n

In general, Cigna requires healthcare providers to request and obtain <\/span>prior authorization (also called precertification) for in-network services<\/span><\/a>. As the patient, you shouldn\u2019t have to do much in order to initiate or complete the request.<\/span><\/p>\n\n\n\n\n\n\n\n\n\n
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Cigna prior authorization for GLP-1 drugs: Comparison chart<\/span><\/h3>\n<\/th>\n<\/tr>\n<\/thead>\n

Drug<\/b><\/td>\nIndication<\/b><\/td>\nCovered?<\/b><\/td>\nCoverage requirements<\/b><\/td>\n<\/tr>\n
Ozempic<\/b><\/td>\nFor adults with type 2 diabetes mellitus<\/span><\/td>\nYes (may require prior authorization)<\/span><\/td>\nMust 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.<\/span><\/td>\n<\/tr>\n
Wegovy<\/b><\/td>\nFor 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\u00a0<\/span><\/td>\nYes (requires prior authorization)<\/span><\/td>\nMust have engaged in behavioral modification and dietary restriction for at least three months<\/span><\/p>\n

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<\/span><\/p>\n

Pediatric patients 12 and older must have an initial BMI at the 95th percentile or higher for age and sex<\/span><\/p>\n

May also be covered for other FDA-approved uses of cardiovascular risk reduction or MASH, if conditions are met<\/span><\/td>\n<\/tr>\n

Mounjaro<\/b><\/td>\nFor adults with Type 2 diabetes<\/span><\/td>\nYes (requires prior authorization)<\/span><\/td>\nMust have a diagnosis of Type 2 diabetes and be 18 years or older<\/span><\/td>\n<\/tr>\n
Zepbound<\/b><\/td>\nFor the treatment of obesity and overweight in adults<\/span><\/td>\nYes (requires prior authorization)<\/span><\/td>\nMust be 18 years or older and must have engaged in behavioral modification and dietary restriction for at least three months<\/span><\/p>\n

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<\/span><\/p>\n

May also be covered for other FDA-approved use of moderate to severe obstructive sleep apnea in adults with obesity, if conditions are met<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

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How to get prior authorization for Ozempic<\/span><\/h3>\n

Ozempic is FDA approved for Type 2 diabetes\u2014as 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).\u00a0<\/span><\/p>\n

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.\u00a0<\/span><\/p>\n

If you don\u2019t 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.\u00a0<\/span><\/p>\n

RELATED: <\/b>Ozempic vs. metformin: Differences, similarities, and which one is better for you<\/b><\/a><\/p>\n

How to get prior authorization for Wegovy<\/span><\/h3>\n

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, <\/span>and <\/span><\/i>have either:<\/span><\/p>\n