Elevance Health / Anthem (CarelonRx)

Insurer + PBM · updated September 2, 2026

Coverage right now

Foundayo™ (orforglipron) Preferred
Saxenda® (liraglutide) Varies
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	Tier 2 with PA/QL on the Essential Drug List. 'BE' flag: applies only if plan includes the weight-loss benefit. NOT on the four California lists (CDI and DMHC, National and Essential) — dropped Tier 2 -> non-formulary there effective 7/1/2025. source	high
Wegovy® tablets (oral semaglutide)	Preferred from Dec 23, 2025	Tier 2 PA/QL. Moved non-formulary -> Tier 2 on the National, National Direct, Direct Plus, Direct Preferred, Essential and Essential Direct lists (Tier 3 -> Tier 2 on Traditional Open). Still non-formulary on all four California lists (CDI and DMHC, National and Essential). source	high
Zepbound® (tirzepatide)	Preferred from Aug 1, 2026	Tier 2 PA/QL on the national and Essential lists; Tier 3 on all four California lists (CDI and DMHC, National and Essential) since 7/1/2025. 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 two California DMHC lists. 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	Tier 3 PA/QL; generic liraglutide at Tier 2 PA/QL. source	high
Saxenda® (liraglutide)	Varies from Apr 1, 2026	Tier 3 -> non-formulary on the National Drug List and the National Direct, Direct Plus and Direct Preferred lists. The same change row also moves the Essential and Essential Direct lists to non-formulary, but Anthem's CT/NY split-closed Essential list current as of 8/1/2026 still prints Saxenda at Tier 3 PA/BE/QL — so Essential members should check their own plan's list. Stays Tier 3 on Traditional Open, and has been non-formulary on all four California lists since 7/1/2025. Generic liraglutide is the covered alternative: Tier 1 on the national and Traditional Open lists, Tier 2 on the Essential lists, and Tier 1 on all four California lists since 1/1/2026 — which makes it the one covered anti-obesity GLP-1 left on the California lists that dropped Wegovy and Saxenda. anthembluecross.com· fm.formularynavigator.com	high

What these rules come to in dollars — every dose, priced under this coverage:

Foundayo 0.8 mg 2.5 mg 5.5 mg 9 mg 14.5 mg 17.2 mg
Wegovy 0.25 mg 0.5 mg 1 mg 1.7 mg 2.4 mg 7.2 mg
Wegovy® tablets 1.5 mg 4 mg 9 mg 25 mg
Zepbound 2.5 mg 5 mg 7.5 mg 10 mg 12.5 mg 15 mg

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

Jul 1, 2025 California lists diverged from the national ones: Wegovy Tier 2 -> non-formulary and Zepbound Tier 2 -> Tier 3 on all four (CDI and DMHC, National and Essential) source
Dec 23, 2025 Wegovy tablets added non-formulary -> Tier 2 on the national and Essential lists source
Jan 1, 2026 Generic liraglutide (weight management) moved non-formulary -> Tier 1 on all four California lists, becoming the covered anti-obesity GLP-1 there after Wegovy and Saxenda came off in July 2025 source
Apr 1, 2026 Saxenda moved Tier 3 -> non-formulary on the National Drug List and the National Direct, Direct Plus and Direct Preferred lists; generic liraglutide is the covered alternative source
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.