Do You Qualify for Injectable Weight-Loss Medication?
On-label criteria, off-label prescribing, and what your insurer requires.
On-label and off-label prescriptions
Prescriptions are classified as either “on label” or “off label” depending on the specific medical condition — the indication, in doctor-speak — for which it was written. On-label indications are the ones approved by the FDA. When the FDA notifies a drug manufacturer that its product got FDA approval, the approval letter lays out the specific indications the approval covers. They are pulled directly from a drug’s pivotal study, a special clinical trial that forms the basis for FDA approval.
The pivotal studies of semaglutide and tirzepatide included, among other patient-selection criteria, minimum BMI thresholds. Those BMI requirements were incorporated into the on-label indications.1
For most drugs, it’s eventually determined that they are useful for conditions beyond the on-label indications. These add-on indications are the “off-label” ones. Unfortunately, health insurers tend to only cover the on-label indications.
What “on-label” says for these medications
| Medication | FDA-approved indications |
|---|---|
| Zepbound (tirzepatide) | Weight reduction and long-term maintenance in adults with obesity, or adults with overweight plus at least one weight-related condition. Also: moderate-to-severe obstructive sleep apnea in adults with obesity. |
| Wegovy injection (semaglutide) | Weight reduction in adults and patients 12 and older with obesity, or adults with overweight plus a weight-related condition. Also: reducing cardiovascular events in adults with established heart disease; and MASH with stage F2–F3 liver fibrosis. |
| Wegovy tablet and Wegovy HD | Same weight and cardiovascular indications, adults only. |
| Saxenda (liraglutide, incl. generic) | Weight reduction in adults, and patients 12 and older weighing more than 60 kg, with obesity — or adults with overweight plus a weight-related condition. |
Important note: “Obesity” used here is defined as a BMI of 30 or above. “Overweight” is defined by a BMI greater than 25 but less than 30. For patients aged 12 to 17, obesity is defined as a BMI at or above the 95th percentile for age and sex.
Indications above are taken from each product’s FDA-approved prescribing information. Review the originals: Zepbound label (FDA) · Wegovy label (FDA) · Saxenda label (FDA) · DailyMed labeling search.
Actual BMI criteria and other medical requirements by insurer
Current as of July 2026. Employer-sponsored plans can differ from their carrier’s standard policy, so confirm your own plan’s terms.
| Plan | BMI required | Other requirements |
|---|---|---|
| Virginia Medicaid (Cardinal Care) | Over 40 — or over 37 with high cholesterol, high blood pressure, or type 2 diabetes | Trial and failure of a non-GLP-1 weight-loss drug; nutritional counseling and activity program; attestation that obesity is disabling and life-threatening; height and weight within 60 days |
| Virginia state employee plans (COVA) | 35 or higher — raised from 27/30 on July 1, 2026 | Current patients become subject to the new threshold when their existing authorization expires |
| Sentara Health Plans | 30 — or 27 with a qualifying condition | Weight-loss treatment plan within the past 6 months, continuing during therapy; current height, weight, and BMI; not using another GLP-1 |
| UnitedHealthcare | 30 — or 27 with a weight-related condition | Used alongside lifestyle modification. Applies only if your employer elected weight-loss coverage. No step therapy |
| Cigna | 30 — or 27 with a qualifying condition | At least 3 months of behavioral and dietary change; age 18 or older |
| Anthem Blue Cross and Blue Shield | Generally 30 — or 27 with a comorbidity | Documented lifestyle attempts. Varies by employer group; many Anthem plans exclude weight-loss drugs entirely |
| Aetna | Generally 30 — or 27 with a comorbidity; some employers select a BMI 35 policy | Documented participation in a weight management program |
| TRICARE | 30 — or 27 to 29 with a weight-related condition | 6 months of documented behavioral and dietary change; a 3-month trial of a generic weight-loss drug that failed to produce 5% loss; prescriber must be an MTF or TRICARE network provider |
| Medicare GLP-1 Bridge | Recorded at start of therapy; no fixed cutoff published | For adults with no Part D-eligible diagnosis. Runs through December 31, 2027 at a $50 monthly copay |
| Virginia marketplace and small-group plans | Not applicable | Virginia's benchmark plan excludes weight-loss drugs, so these plans generally do not cover them at any BMI |
Criteria above are drawn from each payer’s published coverage policy and prior authorization criteria — see sources and payer policy links.
Renewals depend on results. Most plans approve an initial course of 4 to 12 months and require documented weight loss of at least 5% — 4% for Saxenda — before renewing. Virginia Medicaid stops renewals once BMI falls below 25.
The most common reason for denial is not BMI. It is missing documentation — a lifestyle attempt that happened but was never charted, or a qualifying condition that exists in your history but wasn’t submitted. The more complete your record is before we file, the better your odds.
If you don’t meet your insurer’s criteria
- Self-pay. Out-of-pocket, insurer BMI thresholds don’t apply, and manufacturer direct-pay pricing has fallen substantially in the past year. See cash-pay options and denials.
- A different indication. These drugs are also approved for sleep apnea, cardiovascular risk reduction, and MASH liver disease — often an easier coverage pathway if you have one of those conditions.
- A stronger submission or an appeal. Many denials come down to incomplete documentation rather than genuine ineligibility. Our Virginia insurance coverage guide explains the process.
Frequently asked questions
What does on-label mean for weight-loss medication?
On-label indications are the uses the FDA approved, drawn from the drug's pivotal clinical trial. For semaglutide and tirzepatide, those trials included minimum BMI thresholds, so the BMI requirements became part of the approved labeling.
Can I get weight-loss medication off-label?
Yes, if you are paying out-of-pocket. Off-label prescribing by a licensed clinician is lawful and routine. Virginia Bariatric staff have discretion to depart from on-label criteria, including BMI limits, on a case-by-case basis.
What BMI do Virginia insurers require?
Most commercial plans require a BMI of 30, or 27 with a weight-related condition. Virginia Medicaid generally requires over 40, or over 37 with a qualifying condition, and state employee (COVA) plans raised their threshold to 35 on July 1, 2026.
Why was my prior authorization denied?
The most common reason for denial is not BMI. It is missing documentation — a lifestyle attempt that happened but was never charted, or a qualifying condition that exists in your history but was not submitted.
What happens at renewal?
Most plans approve an initial course of 4 to 12 months and require documented weight loss of at least 5% — 4% for Saxenda — before renewing. Virginia Medicaid stops renewals once BMI falls below 25.
Sources
FDA-approved prescribing information for each medication:
Payer coverage policies and prior authorization criteria:
- Virginia Medicaid (DMAS) pharmacy service authorization
- Virginia state employee plans (DHRM benefits)
- Sentara Health Plans pharmacy services
- UnitedHealthcare pharmacy prior authorization
- Cigna coverage policies (pharmacy)
- Anthem clinical guidelines and pharmacy policies
- Aetna pharmacy clinical policy bulletins
- TRICARE formulary and prior authorization forms
- CMS Medicare prescription drug coverage guidance
- Virginia essential health benefits benchmark plan (SCC Bureau of Insurance)
Not sure where you stand?
Our team helps patients verify benefits and submit prior authorizations every day. Start with a consultation and we’ll work through your plan’s requirements together.