Who qualifies for GLP-1? BMI rules, labels and Medicare, in plain English

Who qualifies for GLP-1 medicines?

A GLP-1 medicine is a drug that copies a gut hormone called GLP-1, which helps control blood sugar and appetite. "Who qualifies" means three questions: what the FDA label lists as an approved use, whether the label says you should not take it, and whether your insurance or Medicare plan will pay. A prescriber decides the first two with you. Your plan decides the third.

What the labels say: Wegovy and Zepbound

Section 1 of each label ("Indications and Usage") lists the approved uses. It describes what the FDA approved, not advice for any one person.

Section 1 says "obesity" and "overweight." Section 14 (clinical studies) shows what that meant in the trials. Wegovy's STEP 1 trial enrolled 1,961 adults with a BMI of 30 or more, or 27 to 29.9 plus a condition such as high blood pressure or abnormal blood fats. Zepbound's SURMOUNT-1 trial enrolled 2,539 adults on the same BMI rules. People with type 2 diabetes were left out of both.^1,2

For teens, the Wegovy label's trial enrolled children 12 and older with a BMI at or above the 95th percentile for their age and sex.¹

What about Ozempic and Mounjaro?

Ozempic (semaglutide) and Mounjaro (tirzepatide) are the diabetes versions. Section 1 of the Ozempic label lists blood sugar control in adults with type 2 diabetes, plus lowering heart and kidney risks in adults with type 2 diabetes who have heart disease or chronic kidney disease.³ The Mounjaro label lists blood sugar control in adults and children 10 and older with type 2 diabetes, and lowering heart risk in adults with type 2 diabetes at high risk.⁴ Weight loss is not a listed use for either. See Ozempic vs Wegovy vs Mounjaro vs Zepbound for how the four relate.

What is BMI, and how is it worked out?

BMI, or body mass index, is a quick number that compares weight with height. The CDC defines it as weight in kilograms divided by height in meters, squared.⁵ For example, a person who weighs 90 kg and is 1.75 m tall has a BMI of 90 ÷ (1.75 × 1.75), about 29.4.

Where BMI falls short

The CDC calls BMI "a screening measure" that should be weighed with other factors.⁵ A 2025 Lancet commission of 58 experts said BMI can both underestimate and overestimate body fat. It recommended confirming excess fat with a body fat test or a measure like waist size, except at a BMI over 40.⁶ A 2004 WHO expert group found that in many Asian populations, health risks start at lower BMIs: from 22 to 25 in different groups, and high risk from 26 to 31.⁷

Who should not take a GLP-1? What the labels say

A contraindication is a situation in which the label says a drug must not be used. Section 4 of all four labels lists two:^1–4

• Medullary thyroid cancer (MTC) or MEN 2. MTC is a rare thyroid cancer. MEN 2 (multiple endocrine neoplasia type 2) is an inherited condition that raises its risk. The labels rule out anyone with a personal or family history of MTC, or with MEN 2. More in GLP-1 and thyroid cancer.
• A prior serious allergic reaction to the drug or its ingredients, including anaphylaxis (a sudden, severe whole-body reaction).

Pregnancy. Section 8.1 of the Wegovy and Zepbound labels says weight loss offers no benefit during pregnancy and may harm the fetus, and to stop the drug when a pregnancy is recognized if it is being used for weight loss.^1,2 The Ozempic and Mounjaro labels say to use them in pregnancy only if the benefit justifies the risk.^3,4 If you are pregnant, planning a pregnancy or breastfeeding, talk to your care team. See GLP-1, birth control and pregnancy.

How does insurance decide? Prior authorization and step therapy

Meeting the label does not mean a plan will pay. Each plan has its own drug list, called a formulary, and its own rules, such as:

• Prior authorization is approval your prescriber must get from the plan before it will cover certain drugs, based on the plan's own requirements.⁸
• Step therapy is a kind of prior authorization that asks you to try a cheaper drug on the plan's list first, before moving up a "step" to a more expensive one.⁸

Rules differ by plan and change often, so we do not describe any one insurer's rules; ask your plan what applies. For cash prices, see Zepbound and Wegovy cost without insurance.

Does Medicare cover GLP-1s? Who qualifies for the GLP-1 Bridge?

Medicare's GLP-1 rules are changing, so check Medicare.gov for the latest. As of November 2026, it describes the Medicare GLP-1 Bridge, a short-term CMS program running from July 1, 2026, to December 31, 2027.^9,10 Medicare.gov lists these rules:⁹

• You must have Medicare drug coverage (Part D), be 18 or older and, when you start, have a BMI of 35 or more; or 30 or more with diastolic heart failure, uncontrolled high blood pressure, or chronic kidney disease stage 3a or higher; or 27 or more with prediabetes, a previous heart attack or stroke, or peripheral artery disease with symptoms.
• Your provider must certify that you are using the drug as part of a diet and exercise program.
• Covered drugs: Foundayo (orforglipron) tablets, Wegovy injection or tablets, and the Zepbound KwikPen only.
• The copay is $50 for a one-month supply (28 or 30 days, depending on the drug). It does not count toward your Part D deductible or out-of-pocket limit.
• People already getting a GLP-1 through their Part D plan are not eligible. People with type 2 diabetes, moderate-to-severe sleep apnea or fatty liver disease are not eligible either; Medicare.gov says their Part D plan "should cover GLP-1 medications to treat these conditions."

For your own situation, CMS points people to Medicare.gov/glp1bridge or 1-800-MEDICARE (1-800-633-4227).¹⁰ More on orforglipron in orforglipron weight loss.

Key terms in this article

• GLP-1 medicine: a drug that copies the gut hormone GLP-1 to lower blood sugar and appetite.
• Indication: an approved use listed in section 1 of a drug's label.
• BMI: weight in kilograms divided by height in meters squared.
• Contraindication: a situation in which the label says the drug must not be used.
• Prior authorization: plan approval needed before a drug is covered.
• Step therapy: a rule that you try a cheaper drug first.
• Part D: Medicare's prescription drug coverage.