The two layers of eligibility
Clinical eligibility is whether a GLP-1 is appropriate and safe for you. A licensed clinician decides this, and no telehealth company can override it.
Coverage eligibility is whether someone else will pay. Your insurer sets its own criteria, which are often stricter than the FDA-approved ones.
You can be clinically eligible and have coverage denied. You can also have generous coverage and still not be an appropriate candidate. They are separate questions.
The FDA-Approved Criteria
Weight-management GLP-1s are approved for adults who meet one of two thresholds, used alongside a reduced-calorie diet and increased physical activity.
| Criterion | Threshold | Notes |
|---|---|---|
| Obesity | BMI ≥ 30 | No additional condition required |
| Overweight with a comorbidity | BMI ≥ 27 | Plus at least one weight-related condition |
| Obstructive sleep apnea | Moderate to severe OSA with obesity | A separate approved indication for Zepbound |
| Type 2 diabetes | Diagnosis | Ozempic and Mounjaro are approved for diabetes, not weight management |
What counts as a weight-related condition
- High blood pressure (hypertension)
- Type 2 diabetes or prediabetes
- High cholesterol or dyslipidemia
- Obstructive sleep apnea
- Cardiovascular disease
- Non-alcoholic fatty liver disease
- Osteoarthritis related to weight
- Polycystic ovary syndrome, in some clinical assessments
BMI is a crude measure and clinicians know it. It does not distinguish muscle from fat and performs differently across body types and ethnic groups. A good clinician considers your overall picture, not just the number — but the number is still what most insurers gate on.
What Rules Treatment Out
Absolute contraindications
- A personal or family history of medullary thyroid carcinoma (MTC).
- Multiple Endocrine Neoplasia syndrome type 2 (MEN2).
- Known serious hypersensitivity to semaglutide, tirzepatide, or any component of the formulation.
- Pregnancy. These medications are not used during pregnancy, and providers generally advise stopping well in advance of trying to conceive.
The thyroid contraindication comes from tumors observed in rodent studies. Whether the risk translates to humans is not established, but it carries a boxed warning and is a firm line for prescribers.
Conditions requiring careful evaluation
- A history of pancreatitis — GLP-1s carry a pancreatitis risk signal.
- Gallbladder disease or gallstones. Rapid weight loss raises gallstone risk regardless of the medication.
- Gastroparesis or severe gastrointestinal disease — these drugs slow gastric emptying by design.
- Diabetic retinopathy, where rapid glucose improvement can worsen the condition.
- An active or past eating disorder. Appetite-suppressing medication can interact badly with disordered eating.
- Severe kidney or liver impairment.
- Breastfeeding.
None of these are automatic refusals — they are reasons a clinician needs the full picture. This is exactly why a thorough intake questionnaire is a feature rather than an annoyance.
Be honest on the questionnaire
It is tempting to shade answers to get approved, particularly where cost and access have been frustrating. Don't. The screening questions exist because these medications interact meaningfully with the conditions listed above, and the clinician reviewing your form has no other way to know.
How Telehealth Screening Actually Works
Nearly every provider follows the same shape: an online questionnaire covering medical history, current medications, weight history, and goals, followed by clinician review. Where they differ is what happens next.
Asynchronous review
A clinician reviews your questionnaire without a live conversation. Faster and cheaper, and legal in most states for this purpose. Providers like Eden and Call-On-Doc lean on this model, with Call-On-Doc advertising treatment within 1–2 hours.
Video or phone visit
Some states require a live consultation before prescribing, and some providers require one regardless. Form Health, Calibrate, PlushCare, CVS, and Walgreens all build around real visits. It is slower and gives you someone to actually ask questions.
What providers ask for
- Height and weight, to calculate BMI. Some providers ask for verification.
- Full medical history, including the contraindications above.
- Current medications and supplements, to check interactions.
- Weight history and previous attempts at weight loss.
- Sometimes baseline labs — A1c, lipid panel, kidney and liver function, and a thyroid check.
On Lab Work
Requirements vary widely and the market is not consistent about this. Sesame includes labs in its published program. Form Health includes lab tests in insurance-covered care. PlushCare includes lab access in its membership. Most compounded telehealth providers leave it to clinician discretion.
Baseline labs are generally good practice even where they are not required. They establish a starting point, catch things worth knowing about before you start, and give your clinician something to compare against later. If your provider does not require them and you have not had a check-up recently, consider getting them anyway.
If You Are Told No
A refusal from a clinician is different from an insurance denial, and the responses differ.
Clinically declined
Ask why. If there is a specific contraindication, that reason usually applies at every provider — shopping around for a yes is a bad idea, because the reason does not go away. If it is borderline, a fuller evaluation with your own physician is a more productive next step than a different questionnaire.
If a GLP-1 genuinely is not right for you, Found is one of the few telehealth providers with a formulary of non-GLP-1 weight medications, starting from $49/month.
Coverage denied
A different problem with different solutions — appeals, prior authorization, and self-pay routes. Our insurance coverage guide covers those in detail.
Frequently Asked Questions
What BMI do you need for a GLP-1?
The FDA-approved criteria for weight-management GLP-1s such as Wegovy and Zepbound are a BMI of 30 or above, or a BMI of 27 or above with at least one weight-related health condition — for example high blood pressure, type 2 diabetes, high cholesterol, or obstructive sleep apnea. Insurers often apply the same thresholds, sometimes with additional requirements.
What disqualifies you from taking semaglutide or tirzepatide?
The clearest contraindications are a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2, and a known hypersensitivity to the drug. Pregnancy, breastfeeding, and trying to conceive are also reasons not to take these medications. A history of pancreatitis, gallbladder disease, severe gastrointestinal conditions such as gastroparesis, diabetic retinopathy, or an active eating disorder all require careful clinical evaluation and may rule treatment out.
Do I need blood work first?
It depends on the provider. Some — Sesame and PlushCare, for example — include labs in their programs. Many telehealth companies leave lab requirements to the prescribing clinician's discretion based on your history. Baseline labs are generally good practice, particularly if you have not seen a clinician recently, even where a provider does not require them.
Can a telehealth provider deny me?
Yes, and a good one will. Enrolling in a program is not the same as being approved for medication — a licensed clinician has to determine that a GLP-1 is clinically appropriate for you. Be wary of any service that appears to approve everyone; that is a sign the clinical review is not meaningful.
Related Reading
- GLP-1 side effects — what to expect and when to call someone
- Insurance coverage guide
- Best online GLP-1 providers
- Semaglutide vs tirzepatide
Medical Disclaimer
We're not doctors, and this article is for education only — it isn't medical advice. GLP-1 medications are prescription-only and require evaluation by a licensed healthcare provider. Individual results vary widely, and only a clinician who knows your history can determine what is safe and appropriate for you. See our full medical disclaimer.
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