Cigna GLP-1 Prior Authorization Guide: Verbatim PA Criteria for Wegovy, Zepbound, Foundayo, Ozempic, and Mounjaro (2026)

Cigna covers about 18 million members and publishes its GLP-1 prior-authorization criteria in six separate policy documents. We pulled all six PDFs directly from static.cigna.com on 2026-05-09 and quote them verbatim below. If your prescriber is filling out a Cigna PA form, this is the source-of-truth for every clause they will be asked to attest to.

The six policy documents you need to know

Cigna does not publish a single “GLP-1 master policy.” Coverage rules are split across six PDFs based on (1) whether the drug is being used for weight loss vs type 2 diabetes, (2) whether the plan is Commercial/Employer vs Individual & Family Plan (IFP), and (3) whether quantity limits apply.

Wegovy: PA criteria verbatim from IP0206 §III

Wegovy is Cigna's preferred semaglutide on most Employer Plan formularies. The adult initial-therapy criteria are the 4-prong template that Cigna also uses for Zepbound and Foundayo. Verbatim from IP0206 §III.1.A (pages 10–11):

“Initial Therapy. Approve for 8 months if the patient meets ALL of the following (i, ii, iii, and iv): i. Patient is ≥ 18 years of age; AND ii. Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND iii. Patient meets ONE of the following (a or b): a) At baseline, patient had a BMI ≥ 30 kg/m2; OR b) Patient meets BOTH of the following [(1) and (2)]: (1) At baseline, patient had a BMI ≥ 27 kg/m2; AND (2) At baseline, patient had, or patient currently has, at least ONE of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet”

That is the canonical 11-condition comorbidity list. Many third-party PA explainers list only 3 (hypertension, type 2 diabetes, dyslipidemia) — that is incomplete. Knee osteoarthritis, MASLD/NAFLD, and PCOS in particular are clinically common and frequently overlooked when prescribers document the comorbidity check.

Continuation (§III.1.B, p.11): “Approve for 1 year if … iii. Patient has lost ≥ 5% of baseline body weight; AND iv. The medication will be used concomitantly with behavioral modification and a reduced-calorie diet.”

Pediatric (≥12 to <18) (§III.2): Initial 8 months — BMI ≥ 95th percentile + 3-month behavioral/diet trial. Continuation 1 year — “Patient has had a reduction in BMI of ≥ 1% from baseline.”

MACE risk-reduction pathway (§III.3): a separate 1-year approval is available for patients ≥ 18 with BMI ≥ 27 and established cardiovascular disease — concomitant lifestyle is required, but there is no weight-loss requirement. This is the path for Wegovy patients whose primary indication is the SELECT-trial cardiovascular benefit rather than weight loss. See our SELECT trial cardiovascular benefits (Wegovy MACE) deep-dive for the underlying SELECT data.

Zepbound: PA criteria verbatim from IP0206 §V + CNF 840

Zepbound's adult initial criteria are the same 4-prong template as Wegovy: ≥ 18, 3-month behavioral/diet trial, BMI ≥ 30 OR ≥ 27 + one of the 11 comorbidities, concomitant lifestyle. Verbatim from §V.1.A (p.16): “Initial Therapy. Approve for 8 months.”

Continuation is also identical: “Approve for 1 year if … iii. Patient has lost ≥ 5% of baseline body weight; AND iv. … reduced-calorie diet.”

Moderate-to-severe OSA in obesity pathway (§V.2): Initial 1-year approval requires AHI ≥ 15/hr by sleep study, BMI ≥ 30, and no central sleep apnea or Cheyne-Stokes breathing. Continuation requires ≥ 10% body-weight loss after ≥ 1 year plus prescriber-attested OSA stability — note this 10% threshold is twice the 5% threshold required for the obesity-only Zepbound pathway. The OSA criteria mirror the SURMOUNT-OSA trial eligibility — see our SURMOUNT-OSA tirzepatide / sleep apnea evidence article for the underlying RCT data.

Quantity limits per CNF 840 (verbatim):

“Zepbound 7.5 mg/0.5 mL pens: Quantity limits were changed to 2 mL (4 pens) per 28 days at retail and 6 mL (12 pens) per 84 days at home delivery.”

The same 2 mL (4 pens) per 28 days at retail / 6 mL (12 pens) per 84 days at home delivery applies to the 12.5 mg pens and to all 7.5 / 10 / 12.5 / 15 mg/0.5 mL vials. No overrides. If you are on a higher monthly dose schedule, plan refill cadence accordingly.

Foundayo (orforglipron): PA criteria from IP0206 §II

Foundayo (orforglipron — Eli Lilly's oral non-peptide GLP-1 receptor agonist) was added to IP0206 effective 04/30/2026. The cover page, verbatim: “Foundayo™ (orforglipron tablets – Eli Lilly).” Adult initial criteria (§II.1.A, p.9) use the identical 4-prong framework as Wegovy and Zepbound — “Approve for 8 months” — and continuation (§II.1.B) requires the standard ≥ 5% baseline weight loss for the 1-year reauthorization.

One important caveat: Foundayo is NOT yet listed in CNF 684 as of the 02/25/2026 last selected revision. CNF 684 is the prior-authorization template that pharmacy benefit managers operationalize at the point of sale. IP0206 (the Drug Coverage policy) is the canonical clinical-criteria document for now. If your pharmacy returns “requires PA — not on formulary,” ask your PA team to reference IP0206 §II rather than CNF 684. Cigna typically syncs CNF 684 within 1–2 quarters of an IP0206 update; check both URLs for the current version.

Mounjaro: type-2-diabetes coverage with the 130-day step rule (CNF 360)

Mounjaro is covered for type 2 diabetes through CNF 360, not IP0206. There is a step-therapy rule that catches a lot of patients off-guard. Verbatim coverage gate, p.3:

“Bydureon BCise, Mounjaro, Trulicity, Victoza, liraglutide (generic to Victoza): If criteria for previous use of an oral medication for diabetes (not including Rybelsus or single-entity metformin) in the past 130 days are not met at the point of service, OR if the patient is < 10 years of age, coverage will be determined by Prior Authorization criteria.”

Two practical implications:

• Metformin alone does NOT satisfy the step. A patient who has been on metformin monotherapy for years will still trigger PA. The step requires a different oral antidiabetic in the 130-day lookback (e.g., a sulfonylurea, DPP-4 inhibitor, SGLT2 inhibitor, or thiazolidinedione).
• Rybelsus does NOT satisfy the step. Counter- intuitive but explicit — Rybelsus is itself a GLP-1 (oral semaglutide), so Cigna does not let it serve as the step for Mounjaro.

Approval criterion (verbatim, p.4): “Approve for 1 year if … B) If the request is for Bydureon BCise, Mounjaro, Trulicity, Victoza, liraglutide (generic to Victoza): Approve if the patient is ≥ 10 years of age.”

Pediatric age change (verbatim, History 01/07/2026): “Mounjaro was added to the list of agents approved if the patient is ≥ 10 years of age (previously approved if the patient was ≥ 18 years of age).” This is recent — most third-party explainers and PA letter templates still cite the old ≥ 18 threshold.

Ozempic: type-2-diabetes coverage through CNF 360

Ozempic shares CNF 360 with Mounjaro but is grouped with the oral/short-acting GLP-1s for the step rule. Verbatim, p.3:

“Byetta, exenatide (generic to Byetta), Ozempic, Rybelsus: If criteria for previous use of an oral medication for diabetes (not including Rybelsus or single-entity metformin) in the past 130 days are not met at the point of service, OR if the patient is < 18 years of age, coverage will be determined by Prior Authorization criteria.”

Approval criterion (verbatim, p.4): “Type 2 Diabetes Mellitus. Approve for 1 year if … A) If the request is for Byetta, exenatide (generic to Byetta), Ozempic, Rybelsus: Approve if the patient is ≥ 18 years of age.”

The off-label-for-weight-loss block (verbatim, p.5): “The GLP-1 agonists … in this policy are not FDA-approved for weight loss in a patient who is overweight (body mass index [BMI] ≥ 27 kg/m2) or obese (BMI ≥ 30 kg/m2) without type 2 diabetes.” The policy also includes an explicit no-stacking rule with Wegovy, Zepbound, and Saxenda — you cannot have two weight-loss-indicated GLP-1s approved simultaneously.

Plan-tier overlay: Commercial vs IFP vs MA-PD vs Medicaid

Standard disclaimer (IP0206 / CNF 684 / CNF 360 p.1, verbatim): “the terms of a customer's particular benefit plan document … may differ significantly from the standard benefit plans.” Translation: the policies above are the default; your specific employer or plan can override any of them.

• Commercial / Employer: Express Scripts manages most Cigna pharmacy benefits. IP0206 + CNF 684 are the operative templates. EncircleRx Cardiodiabesity carve-outs (CNF 951) may add or remove plan-specific conditions.
• Individual & Family Plan (IFP): Diabetes GLP-1s are governed by IP0702, NOT CNF 360. If you have a Healthcare.gov / state-exchange Cigna plan, your prescriber should reference IP0702 specifically.
• Medicare Advantage Prescription Drug (MA-PD): Wegovy, Zepbound, and Foundayo for weight-loss-only indications are statutorily excluded from Part D coverage (Social Security Act §1860D-2(e)(2)(A)). However, the Wegovy MACE indication and the Zepbound OSA indication are Part D-coverable on most Cigna MA-PD plans because the indication is non-weight-loss. See our Medicare Part D coverage guide for the broader MA-PD context.
• Medicaid managed care: Cigna's Medicaid footprint is small (Healthspring legacy). State Preferred Drug Lists (PDLs) supersede the Cigna policies above. Check your state Medicaid PDL directly.
• Benefit Exclusion Override (IP0621): for members whose plan excludes obesity drugs entirely but who can demonstrate medical necessity. This is the “last resort” pathway. Approval is plan-specific and discretionary.

What does this actually mean for your PA submission?

The most common reasons Cigna PA submissions for GLP-1 weight-loss drugs are delayed or denied:

• Comorbidity not documented from the 11-condition list. If a patient has BMI 27–29.9, the prescriber must explicitly name one of the 11 conditions in the chart. Saying “has metabolic risk factors” is not enough — the policy requires one of the named diagnoses.
• No documented 3-month behavioral / dietary trial. The chart needs to show this. A single line in the assessment (“patient has tried diet and exercise for the past year”) typically passes; a chart with no mention of any dietary intervention typically fails.
• Trying to use Mounjaro or Ozempic for weight loss without type 2 diabetes. CNF 360 explicitly excludes this. Use Wegovy or Zepbound under IP0206 instead, or pursue a compounded semaglutide / tirzepatide if the patient cannot tolerate brand pricing — see our compounded semaglutide telehealth provider directory for cash-pay options.
• Step therapy not satisfied with metformin alone. For Mounjaro / Ozempic / Trulicity / Victoza, the prescriber must document a non-metformin, non-Rybelsus oral antidiabetic in the past 130 days. If the patient is metformin-naive and has only failed metformin, the chart needs to reflect a trial of a sulfonylurea, DPP-4, SGLT2, or TZD as well — or the PA will go to manual review.
• Reauthorization without ≥ 5% baseline weight loss. For continuation of Wegovy / Zepbound / Foundayo at month 8, the policy requires the prescriber to attest to a measured ≥ 5% loss from baseline. Submitting reauth without this attestation will trigger denial.

If Cigna denies your GLP-1: appeals + alternatives

If your PA is denied, Cigna's formal appeal process gives you 180 days to submit a written appeal (commercial plans). Steps:

1. Request the written denial letter that names the specific policy clause your submission failed to satisfy.
2. Have your prescriber draft a Letter of Medical Necessity that addresses that specific clause — see our GLP-1 PA letter generator which embeds the IP0206 / CNF 360 / CNF 684 criteria into the letter template.
3. File the appeal within 180 days; include the LOMN, baseline BMI, comorbidity documentation, prior medication trial history, and (if reauth) the documented ≥ 5% loss calculation.
4. If the internal appeal is denied, request an external review through Cigna's independent review organization (IRO). External review decisions are binding.

While the appeal is in flight, many patients use cash-pay compounded semaglutide or tirzepatide as a bridge. For our verified telehealth provider directory and pricing index, see best semaglutide providers and best tirzepatide providers.

Verification log

Every Cigna policy URL cited in this article was verified HTTP/2 200 by direct curl to static.cigna.com on 2026-05-09. PDF text was extracted with pdftotext -layout and quoted literally. The version stamps in the document headers as of that date are recorded in the policy table near the top of this article.

The following items are not in this article because they could not be verified to a specific policy clause in this pass:

• Wegovy / Ozempic / Mounjaro DQM (quantity limit) policies — these are separate Cigna policy files (different from CNF 840) and were not retrieved this pass. Flag for follow-up.
• The exact list of state Medicaid programs where Cigna Healthspring participates and how their PDLs handle GLP-1s — state-by-state and changes annually.
• The full text of CNF 951 (EncircleRx Cardiodiabesity) — this policy modifies coverage on plans with the EncircleRx carve-out but was not extracted here.