Two entirely different questions get asked in the same sentence, and the confusion causes a lot of unnecessary despair.
The first is whether you meet the criteria for the drug. That is a public rule, printed on the label, and you can check it yourself in about ninety seconds.
The second is whether your insurer will pay. That has almost nothing to do with the first.
The clinical thresholds
| Product | Molecule | Approved for | Threshold |
|---|---|---|---|
| Wegovy | Semaglutide | Weight management; CV risk reduction | BMI ≥30, or ≥27 with a comorbidity |
| Zepbound | Tirzepatide | Weight management; obstructive sleep apnoea | BMI ≥30, or ≥27 with a comorbidity |
| Ozempic | Semaglutide | Type 2 diabetes; CV risk in T2D | Diagnosis of type 2 diabetes |
| Mounjaro | Tirzepatide | Type 2 diabetes | Diagnosis of type 2 diabetes |
Wegovy is also approved for adolescents aged 12 and over meeting equivalent criteria, which is covered separately in GLP-1s for teenagers.
Two things follow from that table that people consistently miss.
Ozempic is not a weight-loss drug in regulatory terms. It is the same molecule as Wegovy, and it is prescribed off-label for weight constantly, but the licensed product for weight management is Wegovy. This distinction matters enormously for insurance, since a plan covering Ozempic for diabetes has a straightforward basis for refusing it for weight. The full comparison is in Ozempic versus Wegovy.
Zepbound has a second indication. It was approved for moderate-to-severe obstructive sleep apnoea in adults with obesity, and that indication has become one of the more reliable routes to coverage — the detail is in Zepbound for sleep apnoea.
≥30
BMI qualifying on its own, with no comorbidity required
≥27
BMI qualifying when paired with one weight-related condition
~40%
Share of US adults meeting the BMI 30 threshold
CDC
The comorbidity list
If your BMI sits between 27 and 30, one qualifying condition changes everything. The commonly accepted list:
- Hypertension
- Type 2 diabetes or prediabetes
- Dyslipidaemia — raised LDL or triglycerides
- Obstructive sleep apnoea
- Established cardiovascular disease
- Non-alcoholic fatty liver disease, now more often called MASLD — which now has a licensed semaglutide indication of its own
- Osteoarthritis, particularly weight-bearing joints
- Polycystic ovary syndrome — see GLP-1s and PCOS
The practical point: a great many people in this BMI band have an undiagnosed qualifying condition. Untreated sleep apnoea is extraordinarily common and frequently undiagnosed. Prediabetes affects a large share of adults who have never been tested. If you are in the 27 to 30 range and have never had a sleep study or an HbA1c, you may be eligible and not know it.
Where insurance departs from the label
This is the part that surprises people. Meeting the FDA indication is the floor, not the bar. Plans routinely add:
- A documented BMI history — often six or twelve months of recorded weights, not a single reading
- Prior participation in a supervised weight-management programme, sometimes for three to six months
- Step therapy — failing an older, cheaper drug such as phentermine or orlistat first
- Higher BMI thresholds than the label, with 35 or even 40 sometimes required
- Exclusion of weight-loss drugs entirely, which remains common and is entirely lawful
That last one is the wall most people hit. Medicare Part D is statutorily barred from covering drugs for weight loss, which is why the cardiovascular and sleep apnoea indications have mattered so much — they are not weight-loss indications. That whole story is in the Medicare obesity drug fight and the federal pricing deal, and employers have been retreating too, as covered in when employers drop coverage.
You were not turned down for being insufficiently unwell. You were turned down by a formulary that excluded the category before it ever looked at you.
If you qualify clinically but not financially
Several routes, in rough order of how well they work.
Appeal properly. Denials are frequently overturned, and the indication you apply under is often the whole game. A documented cardiovascular history or a positive sleep study changes which policy applies. The mechanics are in appealing a prior authorisation.
Manufacturer self-pay programmes. Both manufacturers now sell directly at prices far below list for people paying cash — see cash-pay and direct pricing and the broader picture in what it actually costs.
Telehealth platforms, with the caveats set out in the telehealth business.
Compounded product, which is a genuinely different risk proposition and is covered in choosing a compounding pharmacy and shortages and compounding.
If you do not qualify
Then you do not, and a prescriber who writes anyway is doing you no favours.
BMI under 27 with no comorbidity is outside the studied population. The trials that established the benefit did not enrol people at that weight, so nobody knows what the risk-benefit looks like there — and the side effects are identical regardless of your starting weight.
If you do qualify, the fortnight before the first injection is the one that does the most work — see how to start a GLP-1.
The ninety-second check
Work out your BMI. If it is 30 or over, you meet the indication. If it is 27 to 30, find out whether you have a qualifying condition — and if nobody has ever checked you for sleep apnoea or prediabetes, that is the first appointment to make.
Everything after that is a coverage fight, and coverage fights are winnable in a way that eligibility is not.