How to qualify for a GLP-1: the criteria, plainly

Gate one: the medical criteria

What the FDA approved each drug for sets the baseline. For the weight-management brands (Wegovy, Zepbound, Saxenda), the adult criteria are a BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related health condition. Those conditions commonly include high blood pressure, high cholesterol, type 2 diabetes, and obstructive sleep apnea. Zepbound also carries a separate approval for moderate-to-severe obstructive sleep apnea in adults with obesity.

For the diabetes brands (Ozempic, Mounjaro, Trulicity, Rybelsus), the criterion is type 2 diabetes, and they are prescribed to improve blood sugar. They are often used off-label for weight, which is a coverage question more than a medical one.

Gate two: your insurer

This is where most people actually get stuck. Meeting the label does not mean your plan pays. Common extra requirements include a higher BMI threshold than the label, documented participation in a supervised diet or lifestyle program for a set number of months, evidence you tried and failed other approaches, prior authorization paperwork from your prescriber, and re-authorization showing you lost a certain percentage to continue. Some plans exclude weight-loss medication entirely, in which case no amount of qualifying helps and the conversation shifts to self-pay or a different drug.

What disqualifies you

Some things rule these drugs out regardless of BMI: a personal or family history of medullary thyroid cancer or MEN2 (a boxed warning for the class), a known serious allergy to the drug, and pregnancy or planning pregnancy. A history of pancreatitis, gallbladder disease, severe gastrointestinal disease, or diabetic retinopathy does not automatically disqualify you but changes the risk-benefit discussion. Be upfront about all of it; this is what the consultation is for.

How to prepare for the appointment

• Know your numbers. Current weight and height (for BMI), and any relevant labs (A1C, cholesterol, blood pressure).
• Bring your weight-related conditions. Sleep apnea, hypertension, prediabetes, PCOS, and fatty liver all strengthen the case at BMI 27 to 30.
• Bring your history. What you have tried, for how long, and what happened. Insurers often want this documented, and it is easier if you have it written down.
• Ask about prior authorization directly. Ask what your plan requires before you leave, so the paperwork starts immediately rather than after a denial.

Our free eligibility checker walks the label criteria in a minute, and our prescription post covers the appointment itself.

If you do not qualify (yet)

A denial is not always final. Ask specifically why, since the fix is often documentation rather than eligibility. Appeals succeed reasonably often when a prescriber supplies the missing evidence. If your plan excludes the category outright, ask about the diabetes-labeled option if you have diabetes, about manufacturer savings programs, or about self-pay pricing. What is not a good answer is unregulated online sources selling these drugs without a prescriber.