HealthRX.com · Printable coverage checklist
Kaiser Zepbound request record: trials, criteria and grievance
Confirm your plan covers weight-loss medicines, list every earlier medicine with dates and measured results, and check the record against Kaiser Northwest's published criteria before the request goes in. If Kaiser says no, record the criterion it cites and each grievance step.
Your Kaiser plan
Kaiser region and plan name
Does the plan cover weight-loss medications?ask Pharmacy Services in your home region
Kaiser prescriber and department
Use on the requestweight management or obstructive sleep apnea
Earlier medicines, with dates and results
| Medicine | Start date | Stop date | Highest dose | Weight change | Why it stopped |
|---|---|---|---|---|---|
Before the request goes in
- Weight and BMI measured in the last month
- Hypertension, diabetes or hyperlipidemia documented, if BMI is 27 to 29
- Current diet and exercise program noted in the chart
- Two earlier weight-loss medicines tried for 3 months each, or the reason none can be used
- Semaglutide trial dates and result, or the reason it cannot be used
- For sleep apnea: sleep study date, AHI and weight at the time of the study
Kaiser Northwest criteria to check against
- Zepbound is covered for weight loss only for members whose plan covers weight-loss medications.[1]
- An adequate trial of an earlier medicine means 3 months of treatment.[1]
- A semaglutide trial of at least 6 months and a bariatric medicine chart review come before Zepbound, unless semaglutide cannot be used.[1]
- Approval lasts 12 months; renewal needs 5% or greater weight loss achieved and maintained.[1]
- Mounjaro for type 2 diabetes is also non-formulary in the Northwest region, after metformin and other steps including semaglutide 2 mg weekly for at least 3 months.[2]
Ask Kaiser Pharmacy Services or member services
- Which region's criteria apply to my plan, and where are they published?
- Does my plan include coverage for weight-loss medications?
- Which criterion did the review find missing?
- How do I file a grievance, and how long does Kaiser have to answer?
- Who handles external review for my plan in my state?
If Kaiser says no
Date of the decision and the criterion cited
Grievance filed on, with reference number
Records added to the grievance
External review: agency, date requested, outcome
Sources for the facts on this sheet
- Kaiser Foundation Health Plan of the Northwest. Kaiser Permanente Northwest Region Criteria for Coverage: tirzepatide (Zepbound). Accessed 2026-10-18. https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-zepbound-nw-en.pdf
- Kaiser Foundation Health Plan of the Northwest. Kaiser Permanente Northwest Region Criteria for Drug Coverage: tirzepatide (Mounjaro). Accessed 2026-10-18. https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/nw/kp-mounjaro-nw-en.pdf
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.