Cigna GLP-1 coverage: PA criteria, Express Scripts formulary, 2026 rules

Cigna — the health insurance arm of The Cigna Group (NYSE: CI) — covers GLP-1 receptor agonists across commercial, Medicare Advantage, and marketplace plans, but coverage rules depend on which Cigna entity administers the plan, whether Express Scripts or another PBM manages the pharmacy benefit, and whether the employer has opted into GLP-1 weight-loss coverage. In May 2025, Cigna's Evernorth division launched a first-of-its-kind pharmacy benefit offering that caps GLP-1 weight-loss drug copays at $200/month through direct manufacturer negotiations, signaling a major shift in how Cigna-affiliated plans may approach GLP-1 access.

This guide maps Cigna's GLP-1 coverage policies, details prior authorization criteria for diabetes and weight-loss indications, explains the Express Scripts National Preferred Formulary's role in GLP-1 coverage, and identifies common denial reasons and appeal pathways. It is independent information and not medical advice or reimbursement guidance for a specific patient or plan.

Quick answer

Key policy dates:

• 2025 (ongoing): Cigna manages GLP-1s as specialty medications requiring PA, typically classified as Tier 4 (non-preferred specialty) drugs
• May 2025: Evernorth launches new pharmacy benefit option capping Wegovy and Zepbound copays at $200/month through direct manufacturer negotiations
• 2026: Express Scripts National Preferred Formulary excludes Wegovy injection, Wegovy tablets, Zepbound pens, and Saxenda from the national formulary; Zepbound vials are the preferred weight-loss GLP-1 option

Who this is for

• Cigna commercial members and their prescribers navigating GLP-1 prior authorization
• Express Scripts PBM members whose pharmacy benefits are managed by Express Scripts under a Cigna-affiliated plan
• Benefit verification specialists and hub teams handling Cigna pharmacy claims
• Market access teams at GLP-1 manufacturers tracking Cigna/Evernorth/Express Scripts policy
• Employer benefits administrators evaluating Cigna's Evernorth GLP-1 cost-cap option

Source standard

Every fact in this guide is sourced from Cigna National Formulary coverage policies, Express Scripts National Preferred Formulary documents, Evernorth press releases, and CMS publications dated 2025–2026. Cigna coverage rules vary by plan, state, and employer. Always verify current coverage by calling the member services number on your Cigna card or checking my.cigna.com.

Cigna, Express Scripts, and Evernorth: how they relate

Understanding Cigna's GLP-1 coverage requires understanding the corporate structure:

• The Cigna Group: Parent company. Owns Cigna HealthCare (insurance), Evernorth Health Services (PBM and services), and Express Scripts (PBM)
• Cigna HealthCare: The insurance entity that underwrites commercial, Medicare, and marketplace plans. Sets medical coverage policy
• Express Scripts: The pharmacy benefit manager that administers prescription drug benefits for many Cigna plans and for non-Cigna employer clients. Express Scripts maintains the National Preferred Formulary — the formulary used by many Cigna commercial plans
• Evernorth Health Services: The health services division that includes Express Scripts, Evernorth Care Management, and other services. Evernorth negotiates directly with pharmaceutical manufacturers and designs benefit options

For GLP-1 coverage, this means:

1. A Cigna commercial member may have their pharmacy benefit managed by Express Scripts, which uses the Express Scripts National Preferred Formulary
2. The Express Scripts National Preferred Formulary (2026) excludes Wegovy injection, Wegovy tablets, and Zepbound pens from its formulary — listing Zepbound vials as the preferred weight-loss GLP-1 option
3. However, Cigna plans that have elected GLP-1 weight-loss coverage can override these exclusions through PA or non-formulary exception processes
4. The May 2025 Evernorth benefit option — which caps GLP-1 copays at $200/month — is a separate plan-level election that employers must opt into

GLP-1 coverage by indication

Type 2 diabetes GLP-1s — PA criteria

Cigna's National Formulary coverage policy for diabetes GLP-1 agonists (policy CNF_360, reviewed June 11, 2025) covers Ozempic, Mounjaro, Rybelsus, Trulicity, Victoza, and exenatide with prior authorization.

Initial authorization criteria for diabetes GLP-1s:

Cigna's policy does not publish single universal criteria for all GLP-1s; instead, criteria vary by drug and indication. General themes across Cigna's GLP-1 PA policies:

1. Documented diagnosis of type 2 diabetes mellitus (A1c ≥6.5%, fasting plasma glucose ≥126 mg/dL, or 2-hour OGTT ≥200 mg/dL)
2. Recent A1c test (typically within 3–6 months), recorded in medical records, from a certified laboratory
3. Trial and failure of, or contraindication to, metformin at maximum tolerated dose
4. For non-preferred GLP-1s (varies by formulary): trial and failure of preferred GLP-1s

Step therapy hierarchy (typical):

• Preferred GLP-1s: Ozempic, liraglutide (Victoza generic)
• Non-preferred GLP-1s: Mounjaro, Trulicity, Rybelsus — may require trial and failure of preferred agents

Approval duration: Typically 12 months for continuation

Required documentation checklist for PA submission:

• Complete diabetes history and diagnosis date
• Current A1c and date of test
• List of all previous diabetes medications with dates, dosages, and outcomes
• Documentation of step therapy compliance or exception rationale
• Current height, weight, BMI
• Comorbidities (cardiovascular disease, kidney disease, etc.)

Weight-loss GLP-1s — PA criteria

Cigna covers Wegovy, Zepbound, and Saxenda for chronic weight management on commercial plans that have elected GLP-1 weight-loss coverage. The Cigna National Formulary coverage policy for weight-loss GLP-1 agonists (policy CNF_684) establishes detailed criteria.

Wegovy initial therapy criteria (chronic weight management — adult):

1. Patient is ≥18 years of age
2. Patient will use the medication with a reduced-calorie diet and increased physical activity
3. Baseline BMI ≥30 kg/m² (obesity), OR baseline BMI ≥27 kg/m² (overweight) with at least one weight-related comorbidity:
   • Hypertension
   • Type 2 diabetes
   • Dyslipidemia
   • Obstructive sleep apnea
   • Coronary artery disease
   • Polycystic ovary syndrome (PCOS)
4. Patient has participated in a comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity) prior to drug therapy
5. No contraindications (personal or family history of MTC or MEN 2)

Wegovy continuation criteria (after 1 year):

1. Patient is ≥18 years of age
2. Baseline BMI was ≥27 kg/m²
3. Patient meets one of the following:
   • Prior myocardial infarction
   • Prior stroke
   • History of symptomatic peripheral arterial disease (intermittent claudication with documented arterial obstruction, or prior revascularization, or amputation due to atherosclerotic disease)
4. Used with behavioral modification and reduced-calorie diet

Note: The continuation criteria for cardiovascular risk reduction are more specific than the initial criteria for chronic weight management, reflecting Cigna's emphasis on documented cardiovascular benefit for ongoing coverage.

Zepbound initial therapy criteria (chronic weight management — adult):

1. Patient is ≥18 years of age
2. Patient will use the medication with a reduced-calorie diet and increased physical activity
3. Baseline BMI ≥30 kg/m², OR baseline BMI ≥27 kg/m² with qualifying comorbidity (same list as Wegovy)
4. Patient has tried and failed or has contraindication to a GLP-1 agonist (e.g., Wegovy or Saxenda) — this is a step therapy requirement specific to Cigna's Zepbound policy
5. No concurrent use with other GLP-1 or GIP/GLP-1 agonists

Pediatric coverage (Wegovy and Saxenda only):

• Wegovy: Patient ≥12 years; BMI ≥95th percentile for age and sex
• Saxenda: Patient ≥12 years and <18 years; BMI ≥95th percentile for age and sex

Wegovy for cardiovascular risk reduction (MACE): Cigna covers Wegovy for reduction of major adverse cardiovascular events when:

1. Patient has established cardiovascular disease (prior MI, stroke, or symptomatic PAD)
2. Baseline BMI ≥27 kg/m²
3. Patient does not have type 2 diabetes (patients with T2D should use Ozempic)
4. Used with reduced-calorie diet and increased physical activity

Zepbound for obstructive sleep apnea (OSA): Covered when criteria for moderate-to-severe OSA are met, with BMI and sleep study documentation.

Saxenda continuation criteria

For patients who have completed 4 months of initial Saxenda therapy, continuation is approved for 1 year if:

1. Patient is ≥18 years (or ≥12 and <18 years for pediatric criteria)
2. Baseline BMI meets criteria (≥30 for adults, ≥95th percentile for pediatrics)
3. Used concomitantly with behavioral modification and reduced-calorie diet

Express Scripts National Preferred Formulary — GLP-1 exclusions

The 2026 Express Scripts National Preferred Formulary (EXCL-NPF-26) lists the following weight-loss GLP-1 medications as excluded:

This means that for plans using the standard Express Scripts National Preferred Formulary:

• Wegovy in any form is excluded
• Zepbound pens are excluded; only Zepbound vials may be covered
• Members cannot receive Wegovy or Zepbound pens without a non-formulary exception

However, plans that elect the Evernorth GLP-1 weight-loss benefit option override these exclusions and provide access to both Wegovy and Zepbound (including pens) with the $200/month copay cap.

For diabetes GLP-1s, the Express Scripts formulary maintains broader coverage:

• Ozempic, Mounjaro, Trulicity, and Rybelsus are available on the formulary for diabetes with PA and quantity limits
• Preferred diabetes GLP-1s and step therapy requirements are listed in the formulary's indication-based management section

Evernorth $200/month GLP-1 benefit option

In May 2025, Evernorth announced a pharmacy benefit offering that represents a significant shift in GLP-1 access strategy:

• Copay cap: Monthly copay for GLP-1 weight-loss medications capped at $200, which counts toward the annual deductible
• Savings: Patients can save up to $3,600/year compared to manufacturer cash programs
• Simplified PA: Prior authorization processes are simplified and automated for faster access
• FDA-approved medications only: Members receive FDA-approved Wegovy or Zepbound through Express Scripts' pharmacy benefit with safety checks
• Employer opt-in required: This is not automatic; employers must elect this benefit option for their plan

This offering positions Cigna/Express Scripts as the first major PBM to negotiate direct GLP-1 pricing with manufacturers and pass savings to patients through a capped copay model.

Formulary tier placement and cost sharing

GLP-1 tier placement on Cigna plans typically follows this structure:

Typical member cost-sharing for Tier 4 specialty drugs on Cigna commercial plans ranges from $25–$100/month after deductible, but can be significantly higher on plans without negotiated GLP-1 pricing. The Evernorth option caps this at $200/month.

Common denial scenarios and how to address them

Denial: "Weight-loss medication excluded — plan does not cover anti-obesity drugs"

Many Cigna commercial plans — especially self-funded employer plans and marketplace plans — exclude GLP-1 weight-loss medications. Cigna individual and family plans typically exclude GLP-1s for weight loss while covering medications like Contrave or Qsymia.

Options:

1. Check for MACE, MASH, or OSA indications: If the patient has established cardiovascular disease, MASH, or moderate-to-severe OSA, Wegovy or Zepbound may be covered under those specific indications rather than the weight-loss exclusion
2. Employer plan amendment: Contact the employer's benefits administrator to ask whether GLP-1 weight-loss coverage can be added, or whether the Evernorth $200/month cap option is available
3. Formulary exception: Submit a non-formulary exception request with supporting clinical documentation

Denial: "Step therapy not met — trial of preferred GLP-1 required"

Cigna's Zepbound policy requires trial and failure of a GLP-1 agonist (e.g., Wegovy or Saxenda) before Zepbound is approved. Some plans also require step therapy for non-preferred diabetes GLP-1s.

Options:

1. Document prior GLP-1 trials: Provide records of all prior GLP-1 medication trials, including start dates, durations, dosages, and reasons for discontinuation
2. Request step therapy override: Submit a clinical rationale if the patient has a documented contraindication or severe adverse reaction to the preferred agent
3. Specialist letter: A letter from an endocrinologist supporting the medical necessity of the specific GLP-1 can strengthen the request

Denial: "Drug Quantity Management — claim exceeds days supply limit"

Cigna's Drug Quantity Management policy for weight-loss GLP-1s (policy CNF_894, reviewed May 21, 2025) sets specific quantity limits:

• Saxenda: 5 pens per 30 days
• Wegovy: 4 pens per 28 days (by strength)
• Zepbound: 4 pens/vials per 28 days (by strength)

If a claim is denied due to quantity limits, the prescriber can submit a quantity limit exception request with clinical justification.

Denial: "Wegovy/Zepbound excluded from formulary (Express Scripts NPF)"

On plans using the Express Scripts National Preferred Formulary, Wegovy and Zepbound pens are excluded.

Options:

1. Switch to Zepbound vials: The ESI formulary lists Zepbound vials as the preferred weight-loss GLP-1 option
2. Non-formulary exception: Submit a request documenting why Zepbound vials are not appropriate (e.g., patient cannot self-administer from vials, requires pen delivery)
3. Employer plan change: If the employer adopts the Evernorth GLP-1 benefit option, both Wegovy and Zepbound pens become covered

How to verify Cigna GLP-1 coverage

Step 1: Identify your plan type and PBM

Log in to my.cigna.com and check your pharmacy benefit. Identify whether your pharmacy benefit is managed by Express Scripts or another PBM, and note your plan type (commercial group, marketplace, Medicare Advantage).

Step 2: Check formulary coverage

Use the Cigna "Find a Medication" tool or the Express Scripts formulary search to check whether your specific GLP-1 drug is on your plan's formulary and at what tier.

Step 3: Review PA requirements

Visit the Cigna provider portal for coverage policies, or ask your prescriber to check Cigna's National Formulary coverage policies at static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/.

Step 4: Submit PA

Prescribers can submit PA through:

• Cigna Provider Portal (preferred method)
• CoverMyMeds platform
• Fax: Check the specific PA form for the correct fax number
• Phone: Cigna Provider Services

Step 5: Appeal if denied

1. Request the specific denial reason in writing
2. Gather supporting documentation (BMI records, A1c results, prior medication trials, specialist letters, sleep study results for OSA)
3. Submit a first-level appeal within the timeframe specified in the denial letter (typically 60 days)
4. If the first-level appeal is denied, request a second-level appeal or external review through Cigna's grievance process

What to monitor

• Evernorth GLP-1 benefit adoption: As more employers adopt the $200/month copay cap, GLP-1 access through Cigna/Express Scripts will expand significantly
• Express Scripts formulary changes: The 2026 ESI formulary's exclusion of Wegovy and Zepbound pens may change if manufacturer pricing negotiations evolve
• Medicare GLP-1 expansion: CMS's July 2026 Bridge demonstration will create new pathways for Cigna Medicare Advantage members to access GLP-1s for weight management
• State mandates: Several states are considering legislation requiring commercial GLP-1 coverage, which would affect Cigna plans in those states
• New GLP-1 approvals: Orforglipron (Foundayo) and other oral GLP-1s may shift Cigna's formulary strategy and step therapy hierarchies, potentially offering lower-cost alternatives

Sources

• Cigna National Formulary Coverage. "Diabetes – Glucagon-Like Peptide-1 Agonists Prior Authorization Policy (CNF_360)." Reviewed June 11, 2025. https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_360_coveragepositioncriteria_glucagon-like_peptide-1_agonists_pa.pdf
• Cigna National Formulary Coverage. "Weight Loss – Glucagon-Like Peptide-1 Agonists Prior Authorization Policy (CNF_684)." https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.pdf
• Cigna National Formulary Coverage. "Weight Loss – Glucagon-Like Peptide-1 Agonists Drug Quantity Management Policy – Claim Per Days (CNF_894)." Reviewed May 21, 2025. https://static.cigna.com/assets/chcp/pdf/coveragePolicies/cnf/cnf_894_coveragepositioncriteria_weight_loss_glp1_agonists_dqm_claim_per_days.pdf
• Express Scripts. "2026 National Preferred Formulary (EXCL-NPF-26)." Effective April 1, 2026. https://www.express-scripts.com/pdf/formulary/NPE1702_204612.pdf
• Evernorth Health Services. "Evernorth Launches New Benefit Option That Drives Lower Net Cost for Weight Loss Medicines and Limits Patient Cost to No More Than $200 Per Month." May 21, 2025. https://www.evernorth.com/articles/evernorth-launches-new-benefit-option-drives-lower-net-cost-weight-loss-medicines
• Word & Brown General Agency. "Weight Loss Drugs (GLP-1) Insurance Coverage Breakdown By Carrier." Updated May 1, 2026. https://www.wordandbrown.com/NewsPost/Weight-Loss-Drugs-(GLP-1)-Coverage
• Counterforce Health. "How to Get Ozempic and Mounjaro Covered by Cigna in New Jersey." https://www.counterforcehealth.org/post/how-to-get-ozempic-and-mounjaro-covered-by-cigna-in-new-jersey-prior-authorization-appeals-and-medical-necessity-requirements
• CMS.gov. "Coming Soon: CMS to Provide $50 Monthly Access to GLP-1 Medications for Medicare Beneficiaries." 2026. https://www.cms.gov/newsroom/press-releases/coming-soon-cms-provide-50-monthly-access-glp-1-medications-medicare-beneficiaries