Elevance Health / Anthem (CarelonRx)
Insurer + PBM · updated August 8, 2026
Coverage right now
- Foundayo™ (orforglipron) Preferred
- Saxenda® (liraglutide) Non preferred
- Wegovy® (semaglutide injection) Preferred
- Wegovy® tablets (oral semaglutide) Preferred
- Zepbound® (tirzepatide) Preferred
The stable one: kept Wegovy AND Zepbound dual-preferred (Tier 2, PA/QL) through the 2025 upheavals, and added Foundayo fastest of the majors (May 15, 2026). Coverage still contingent on the employer including a weight-loss benefit. No single national criteria PDF — criteria served per-drug via the Anthem Drug List Search.
Drug status
| Drug | Status | Detail | Confidence |
|---|---|---|---|
| Wegovy® (semaglutide injection) | Preferred from Aug 1, 2026 | Tier 2 with PA/QL on the Essential Drug List (inj + oral). 'BE' flag: applies only if plan includes the weight-loss benefit. source | high |
| Wegovy® tablets (oral semaglutide) | Preferred from Aug 1, 2026 | Tier 2 PA/QL. source | high |
| Zepbound® (tirzepatide) | Preferred from Aug 1, 2026 | Tier 2 PA/QL. Device transition underway: KwikPen added at Tier 2 eff 8/1/2026; single-dose pen Tier 3 -> non-formulary eff 10/1/2026 on the CA National list. source | high |
| Foundayo™ (orforglipron) | Preferred from May 15, 2026 | Added NF -> Tier 2 PA/QL across National, Direct, Direct Plus, Direct Preferred lists effective 5/15/2026. source | high |
| Saxenda® (liraglutide) | Non preferred from Aug 1, 2026 | Tier 3 PA/QL; generic liraglutide at Tier 2 PA/QL. source | high |
What preferred, covered and exception only mean
- Preferred
- On the formulary at the plan's best tier for this class. Usually still needs prior authorization — preferred is not the same as automatic.
- Covered
- On the formulary, but not the plan's first choice for this class. Often a higher copay tier than a preferred drug.
- Non preferred
- On the formulary at a disadvantaged tier, or reachable only after trying a preferred drug first.
- Exception only
- Not routinely covered. Obtainable only through a formulary-exception request that meets the plan's published criteria.
- Excluded
- Not on the formulary at all. A benefit exclusion is a different fight from a PA denial and is appealed differently.
- Varies
- The payer's own documents differ by plan or line of business, so a single answer here would be wrong.
- Unknown
- Not yet verified against a primary document. Recorded as absent rather than guessed.
- N/A
- Not applicable to this payer.
Prior authorization criteria
medium- PA required
- Yes — PA flag on all anti-obesity GLP-1s; benefit-exclusion flag means employer opt-in governs.
- Initial BMI
- BMI >= 30, or >= 27 with >= 1 weight-related comorbidity (no numbered national policy document published; criteria served per-drug via Drug List Search links).
- Comorbidities
- Type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea.
- Lifestyle requirement
- 3-6 months documented diet/exercise efforts in the medical record.
- Initial authorization
- ~5-6 initial (varies by plan); renewals 12.
- Reauthorization
- >= 5% weight loss from baseline to continue.
- Step therapy
- No universal GLP-1 step on national commercial lists; some plans add one.
- Quantity limits
- QL flag on all listed agents; specific counts served at drug level.
Primary criteria document:findhonestcare.com
Exceptions and appeals
- Appeal deadline
- 180 days
- Deadline detail
- 180 days internal (typical Anthem commercial).
- Exception route
- ePA via Surescripts (providerportal.surescripts.net), CoverMyMeds, or CenterX (EPIC). Verbal PA 833-293-0659 (M-F 8a-9p ET, Sat 10a-2p).
- Turnaround
- ePA can auto-approve in real time; standard/expedited clocks are state-mandated and not published nationally.
- Where
- Per your denial letter (plan-specific).
Source:carelonrx.com
Dated changes
- May 15, 2026 Foundayo added at Tier 2 PA/QL across major lists — fastest add among the majors source
- Jan 1, 2026 Anthem CA Medi-Cal terminated weight-loss GLP-1 coverage (Wegovy keeps MASH/CV pathways, Zepbound keeps OSA; Reject Code 70 otherwise) source
- Oct 1, 2026 Zepbound single-dose pen Tier 3 -> non-formulary (CA National list); presentation switch to KwikPen source
State variation is real (CA DMHC vs CDI lists differ). CarelonRx sells employers an opt-in GLP-1 weight-management program. Criteria questions: druglist@carelon.com.
These are each payer's standard template. Employer plans customize them, so the same PBM can cover a drug for one employer and exclude it for another — a status here is a starting point, not your plan. A benefit exclusion is also a different fight from a PA denial. Always request your own plan's criteria in writing; you are entitled to them.