GLP-1 Insurance Coverage Checker

This tool estimates how likely a U.S. insurance plan is to pay for a specific GLP-1 medication, based on the four things insurers actually weigh: which drug you were prescribed, why, your plan type, and your BMI. It returns a coverage-chance band (high, medium, or low), a likely copay range, whether prior authorization is typically required, and how strong an appeal would be if you are denied.

The estimate combines a few well-documented rules that drive most real-world decisions:

The logic

• On-label vs off-label. A diabetes drug for diabetes, or a weight-loss drug for obesity, scores far higher than an off-label combination.
• Plan type. Medicare Part D is generally barred by statute from covering drugs used only for weight loss, so weight-loss requests on Medicare score low. Commercial and employer plans vary widely; Medicaid depends on your state.
• BMI thresholds. For weight-management coverage, most plans require a BMI of 30 or higher, or 27 or higher with a weight-related condition such as high blood pressure or sleep apnea.
• Prior authorization. Nearly every GLP-1 requires it, so the tool flags it and tells you how to prepare.

Medical criteria insurers look for

Out of pocket, a month of a GLP-1 can run $1,000–$1,350. With coverage and a manufacturer savings card, the same month can cost as little as $25. Knowing your coverage odds before your appointment lets you pick the drug most likely to be paid for, prepare the documentation your doctor needs, and avoid weeks of back-and-forth with the pharmacy.

• Match the drug to the diagnosis. If your main issue is weight, ask about Wegovy or Zepbound rather than Ozempic — they are approved for it.
• Document a related condition. If your BMI is 27–30, a diagnosed condition like hypertension, sleep apnea, or prediabetes can unlock coverage.
• Have your doctor complete prior authorization thoroughly. Incomplete forms are the top reason for a first denial.
• Ask about step therapy. Some plans pay only after you have tried a cheaper option first; documenting that history speeds approval.
• Check the formulary. Plans often prefer one GLP-1 over another; the preferred one has a lower copay.

Coverage rules change frequently and vary by employer, state Medicaid program, and plan year. Newer FDA approvals — for example, semaglutide for reducing cardiovascular risk, or tirzepatide for obstructive sleep apnea — are gradually expanding what Medicare and commercial plans will pay for. Always confirm your specific plan's current formulary and criteria, and let your prescriber lead decisions about which medication is clinically appropriate for you.