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BMI dropped on a GLP-1? What insurance renewal actually requires

Updated Sep 30, 2026. Numbers in brackets link to the source each fact comes from.

A lower BMI does not, on its own, fail the renewal rules insurers publish on their websites. The renewal rules that could be read for this article compare you with where you started: your BMI when you began the drug, and how much of your starting weight you lost and kept off. The practical risk is paperwork: the plan needs your starting numbers to compare against.

Starting BMI versus today’s BMI

Aetna’s commercial weight-loss policy shows the difference clearly. To start, the patient must have a baseline BMI of 35 or more [1]. For continuation, the wording changes to a BMI of 35 or more at the start of drug therapy [2]. If you switched from another weight-loss drug, Aetna says to use your BMI when you started any drug therapy [3]. So a person who started at 38 and is now at 29 is measured against 38 [2].

The Medicare GLP-1 Bridge works the same way. You must meet its clinical criteria at the time you started the GLP-1, even if that was before you joined Part D or before the Bridge launched [8]. Its BMI thresholds are written as BMI at the time therapy began [9].

What the published renewal rules ask for

Plan What renewal requires
Aetna commercial, weight-loss policy At least 3 months on a stable maintenance dose [4], and at least 5% of starting weight lost, or the first 5% kept off [5]
Medicare GLP-1 Bridge No renewal inside the program: approval covers refills and dose changes through December 31, 2027, unless you switch GLP-1s [10]
Cigna’s EncircleRx program (Evernorth) No set limit on how long an approved patient can stay on the drug [11]; active engagement in its lifestyle program means four weigh-ins and four app check-ins a month [12]
TRICARE Prime and Select Still covered under a previously approved prior authorization [13]

Note the Aetna wording: losing 5% or keeping off the first 5% [5]. Holding steady after the first 5% still meets that test [5].

How long an approval lasts

Approvals run out on a fixed date, and renewal is a new request. Aetna’s policy approves Wegovy for weight loss for 8 months at first and 12 months per renewal [6]. Its tirzepatide terms are the same for weight loss, and 6 months then 12 months for sleep apnea [7]. Premera’s policy update gives Foundayo an initial approval period of 7 months [14]. Check the end date on your own approval letter and start the renewal a few weeks ahead.

What the labels say about staying on the drug

The FDA labels approve these medicines both to reduce excess weight and to keep it off long term, alongside diet and activity [15] [16]. The Zepbound label also tells prescribers to weigh response and tolerability when picking a maintenance dose, and to consider a lower one if needed [17]. A renewal request can quote that language: maintenance is part of the approved use, not an extra.

What to send before the approval expires

  1. Your starting weight and BMI. The date and number from the visit when you began. Without a baseline, the plan has nothing to measure against.
  2. Your current weight, so the percentage lost or kept off is plain.
  3. Your current dose and how long you have been on it, since Aetna, for one, wants time on a stable maintenance dose [4].
  4. The plan’s own continuation wording, quoted back in the request.
  5. Proof of any required program, such as lifestyle-program check-ins if your plan uses one.

If the renewal is refused

You have the right to appeal a refusal and have it reviewed by a third party [18]. Before you do, check whether the refusal is about criteria or about the benefit itself: an approval does not guarantee payment if the plan now excludes the drug [19]. For appeal deadlines, exceptions and cash routes, see what to do when insurance drops GLP-1 coverage and GLP-1 prices without insurance.

Sources

  1. The patient has a baseline body mass index (BMI) greater than or equal to 35 kg/m2. aetna.com, read Sep 27, 2026.
  2. The patient had a baseline body mass index (BMI) greater than or equal to 35 kg/m 2 at the start of drug therapy for weight loss. aetna.com, read Sep 27, 2026.
  3. If the patient transitioned from another drug therapy for weight loss, please consider their baseline BMI at the start of any drug therapy. aetna.com, read Sep 27, 2026.
  4. The patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose. aetna.com, read Sep 27, 2026.
  5. The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss. aetna.com, read Sep 27, 2026.
  6. Wegovy (semaglutide) Injection: Reduction in excess body weight, maintenance of weight reduction long term in patients 18 years of age and older: Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months aetna.com, read Sep 27, 2026.
  7. Tirzepatide (Zepbound/Mounjaro): Obstructive Sleep Apnea (OSA): Initial therapy DOA: 6 months; Continuation of therapy DOA: 12 months Reduction in excess body weight, maintenance of weight reduction long term: Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months aetna.com, read Sep 27, 2026.
  8. Eligible beneficiaries must meet the clinical criteria at the time of GLP-1 therapy initiation. This includes beneficiaries who initiated therapy prior to enrolling in Medicare Part D and/or prior to the July 1, 2026 launch of the Medicare GLP-1 Bridge. cms.gov, read Sep 27, 2026.
  9. The beneficiary is at least eighteen (18) years of age and has a BMI greater than or equal to thirty-five (≥35) at the time of initiation of GLP-1 therapy cms.gov, read Sep 27, 2026.
  10. Your prior authorization is valid (including for refills and dose changes) through December 31, 2027, unless you change GLP-1s. medicare.gov, read Sep 27, 2026.
  11. Currently there are no limits to how long your patient can be on their GLP-1 medication. evernorth.com, read Sep 27, 2026.
  12. Active engagement is defined as four weigh-ins and four app engagements per month. evernorth.com, read Sep 27, 2026.
  13. If you have TRICARE Prime or TRICARE Select, these medications are still covered with a previously approved prior authorization. militaryrx.express-scripts.com, read Sep 27, 2026.
  14. Foundayo (orforglipron) criteria now provide an initial approval period of 7 months. premera.com, read Sep 27, 2026.
  15. to reduce excess body weight and maintain weight reduction long term in adults with obesity or adults with overweight in the presence of at least one weight-related comorbid condition. dailymed.nlm.nih.gov, read Sep 27, 2026.
  16. WEGOVY injection is indicated in combination with a reduced calorie diet and increased physical activity: dailymed.nlm.nih.gov, read Sep 27, 2026.
  17. Consider treatment response and tolerability when selecting the maintenance dosage. If patients do not tolerate a maintenance dosage, consider a lower maintenance dosage. dailymed.nlm.nih.gov, read Sep 27, 2026.
  18. If your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision and have it reviewed by a third party. healthcare.gov, read Sep 27, 2026.
  19. Prior authorization approval does not guarantee payment if a member's benefit plan excludes coverage for the requested medication or indication. southcarolinablues.com, read Sep 27, 2026.