in 4 days Aetna (CVS Health) — Zepbound back as additional preferred on templates See the changelog
WalletNoise

Blue Cross Blue Shield Federal Employee Program (FEP)

National uniform plan (published criteria) · updated September 1, 2026

Coverage right now

Restructured the class for 2026 citing GLP-1 cost growth: Zepbound moved to the Standard-option excluded list (obtainable only via formulary exception meeting policy 5.99.031, which adds a new two-oral-agents step plus preferred-product trial), while Wegovy and Saxenda held at Tier 3 with PA. Focus option does not cover anti-obesity drugs at all. One uniform national plan with genuinely published criteria — the most transparent payer in this corpus.

Drug status

DrugStatusDetailConfidence
Wegovy® (semaglutide injection)Covered
from Jan 1, 2026
Tier 3 non-preferred with prior approval on Standard and Basic (inj + oral tabs incl. 25 mg). Not covered on Focus (exception -> Tier 2 cost share). sourcehigh
Wegovy® tablets (oral semaglutide)Covered
from Jan 1, 2026
Wegovy tablets (1.5/4/9/25 mg) Tier 3 PA on Basic; folded into the Wegovy formulary line. sourcehigh
Zepbound® (tirzepatide)Exception only
from Jan 1, 2026
On the 2026 FEP Blue Standard EXCLUDED DRUG LIST (alternatives: Wegovy, Saxenda, orals). Obtainable via formulary exception meeting policy 5.99.031; approved exceptions pay Tier 3 (Std/Basic) or Tier 2 (Focus). sourcehigh
Foundayo™ (orforglipron)Unknown Not on 2026 FEP formulary documents as of Aug 2026; formulary-exception route available. sourcemedium
Saxenda® (liraglutide)Covered
from Jan 1, 2026
Tier 3 PA on Standard/Basic; generic liraglutide Tier 1 PA on Basic. sourcehigh

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

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

high
PA required
Yes — prior approval on all covered anti-obesity meds; excluded GLP-1s need a formulary exception (which does not change out-of-pocket costs; tier exceptions not allowed).
Initial BMI
Adults 18+: BMI >= 30, OR >= 27 with established CVD or >= 1 weight-related comorbidity. Ages 12-17 (Wegovy/Saxenda): BMI >= 95th percentile.
Comorbidities
Type 2 diabetes, dyslipidemia, or hypertension; plus enumerated established-CVD conditions (CHD, prior MI/revascularization, cerebrovascular, PAD).
Lifestyle requirement
Participation in a comprehensive weight management program (e.g., Teladoc or another program) — required at initiation AND renewal.
Initial authorization
6 (Wegovy/Saxenda/Zepbound; 12 for Wegovy-MASH); renewals 12.
Reauthorization
Lost at least 5% of baseline body weight OR maintained the initial 5% loss. Adolescents: maintained clinically significant weight loss.
Step therapy
NEW FOR 2026, Zepbound only: inadequate response, intolerance or contraindication to at least TWO oral weight-management medications, AND must try and fail TWO preferred products — Saxenda (liraglutide) and Wegovy — unless a valid medical exception. No dual GLP-1/AOM therapy.
Quantity limits
Wegovy 12 single-dose pens/84 days · Saxenda 15 pens/90 days · Zepbound 12 pens/84 days.

Primary criteria document: fepblue.org· fepblue.org· info.caremark.com

Exceptions and appeals

Appeal deadline
See note
Deadline detail
FEHB disputed-claims process (not ERISA): written reconsideration to the carrier within 6 MONTHS of denial; carrier decides within 30 days; then OPM review within 90 days of the carrier's upholding letter; OPM decides ~60 days; then federal court only.
Exception route
Prescriber submits electronically, by fax, or mail using Caremark-hosted FEP forms. Phone 1-877-727-3784 (FEHB/PSHB) or 1-855-344-0930 (Medicare Rx).
Turnaround
Not published on the FAQ; secondary: ~72h standard / 24h urgent.
Where
Per FEP denial letter; OPM review per FEHB brochure Section 8.

Source: ghcscw.com

Dated changes

  • Jan 1, 2026 Zepbound split into new policy 5.99.031 (two-oral + preferred-product step) and moved to the Standard excluded list; generic liraglutide added Tier 1; FEP cited 'rapid increase in the use of weight loss GLP-1s' as the cost driver source
FEHB appeals are NOT ERISA — different deadlines and an OPM review layer. Standard vs Basic: identical criteria and tier, different cost share. Several 2026 consumer sites misreport the Focus exception cost-share table; the official formulary book governs. Policy 5.99.031 requires the preferred products of its own Appendix 3, and publishes that appendix blank — the two it means are named only in the Caremark FEP medication-exchange list, which is the source cited on the PA block. Do not read the blank appendix as no step.
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.