Clinical Eligibility Guide
GLP-1 Eligibility (2026): Who Qualifies and What Disqualifies You
Educational reference • Last reviewed August 5, 2026
Executive Summary
Eligibility for GLP-1 therapy is decided twice. First a clinician decides whether the medication is appropriate for you, using BMI thresholds and contraindication screening. Then, if you want insurance to pay, your plan decides separately using its own criteria — which are usually stricter. People are frequently approved by the first and denied by the second.
This guide covers both: the clinical criteria providers actually apply, the contraindications that rule treatment out entirely, and the practical steps to take if you are declined. It is educational reference, not medical advice — only a clinician who has evaluated you can determine whether treatment is safe for you.
Section 1: Standard Clinical Criteria
Nearly every provider reviewed on this site applies some version of the same two-part threshold, which follows the labeled indications for the FDA-approved products.
Path 1: BMI 30 or higher
A BMI of 30 or above is classified as obesity and generally qualifies on its own, without a second condition.
BMI is weight in kilograms divided by height in metres squared. Most provider intakes calculate it for you.
Path 2: BMI 27+ with a condition
A BMI of 27 or above qualifies if you also have at least one weight-related medical condition. Commonly accepted conditions include:
- Hypertension (high blood pressure)
- Type 2 diabetes or prediabetes
- Obstructive sleep apnea
- Dyslipidemia (high cholesterol)
- Cardiovascular disease
Section 2: Absolute Contraindications
These generally rule out GLP-1 therapy entirely
- !Personal or family history of medullary thyroid carcinoma. GLP-1 receptor agonists carry a boxed warning regarding thyroid C-cell tumors.
- !Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Same reason — this is an absolute contraindication on the label.
- !Pregnancy or breastfeeding. GLP-1 medications are not for use during pregnancy or while nursing.
- !Known hypersensitivity to semaglutide, tirzepatide, or any excipient in the formulation.
For a fuller discussion of who should avoid these medications, see who should not take Ozempic and who should not take Mounjaro.
Section 3: Conditions Requiring Extra Caution
These do not automatically disqualify you, but they change the risk calculation and will prompt a more careful evaluation — sometimes a referral to a specialist.
History of pancreatitis
Frequently listed as a disqualifier by telehealth providers; specialist input is usually needed.
Type 1 diabetes
Hello Alpha lists this among its disqualifying conditions for weight-loss therapy.
Anorexia or bulimia history
Appetite-suppressing medication can interact badly with eating disorder history.
Severe gastrointestinal disease
Gastroparesis and severe GI conditions raise the risk of significant adverse effects.
Gallbladder disease
Rapid weight loss is an established risk factor for gallstone formation.
Diabetic retinopathy
Rapid improvement in blood glucose has been associated with retinopathy progression.
Kidney impairment
Dehydration from GI side effects can worsen renal function.
Thyroid nodules
Warrants discussion given the class boxed warning.
Section 4: Clinical Eligibility vs Insurance Eligibility
Clinical eligibility
Decided by a licensed clinician who has evaluated you.
Based on BMI, comorbidities, contraindications, and your full medical history.
Applies whether you pay cash or use insurance.
Can be assessed asynchronously or by video, depending on the provider.
Insurance eligibility
Decided by your plan, using its own formulary criteria.
Often stricter: documented BMI history, prior weight-loss attempts, specific comorbidities.
Requires prior authorization for most branded weight-loss medications.
Typically takes 7 to 14 days to process, and can be denied even when a clinician approves you.
Section 5: If You Are Declined
- 1.Find out why. A BMI shortfall, a contraindication, and a state-licensure gap are three very different problems with three different solutions.
- 2.Claim your refund if one is owed. Good Life Meds states you receive a full refund of all costs incurred if you are not prescribed, including cancellation of any subscription. Not every provider does this — Hello Alpha states its plan fee is not refundable in some denial scenarios.
- 3.Consider a microdosing program. If your BMI is below the standard threshold, Fitish RX and Hello Dose run lower-dose lanes designed for exactly that situation. Microdosing is not an FDA-approved regimen and the evidence base is thin, so weigh it with a clinician.
- 4.Appeal an insurance denial. A denied prior authorization is not always final. Providers like PlushCare and Shapely will work the process; documented BMI history and prior weight-loss attempts often make the difference.
- 5.Do not shop for a yes. If a clinician declined you because of a contraindication, that judgment is protecting you. Finding a provider who will prescribe anyway is not a win.
Frequently Asked Questions
What BMI do I need to qualify for a GLP-1?
The standard clinical threshold used across the providers reviewed on this site is a BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related medical condition such as hypertension, type 2 diabetes, sleep apnea, or dyslipidemia. Some providers set a slightly different bar — Hello Alpha lists a BMI under 25–27 as disqualifying unless you have a weight-related condition.
Can I get a GLP-1 if my BMI is normal?
Generally no for standard-dose therapy. PlushCare states directly that it does not treat new patients with a normal BMI using weight-loss pharmacotherapy unless the patient provides outside records documenting previous obesity. Some providers run separate lower-dose programs for patients below the standard threshold — Fitish RX and Hello Dose both offer microdosing lanes — but microdosing is not an FDA-approved regimen and evidence for it is limited.
Who absolutely cannot take a GLP-1?
GLP-1 receptor agonists carry a boxed warning regarding thyroid C-cell tumors, and are contraindicated in people with a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2. They are not for use in pregnancy or while breastfeeding. A history of pancreatitis, severe gastrointestinal disease, type 1 diabetes, or an eating disorder such as anorexia or bulimia will also typically rule out treatment or require specialist involvement.
Why was I declined by a telehealth provider?
The most common reasons are a BMI below the clinical threshold, a contraindication in your history, incomplete or inconsistent intake answers, or residency in a state where that provider's clinicians are not licensed. Some providers refund you if declined — Good Life Meds states you receive a full refund of all costs incurred — while others do not. Check that policy before paying.
Does insurance use the same eligibility criteria?
No, and this catches people out. A clinician may consider you an appropriate candidate while your insurer still denies coverage, because plan formularies impose their own criteria — often requiring documented BMI history, prior weight-loss attempts, or specific comorbidities. Prior authorization is where those two sets of criteria collide, and it typically takes 7 to 14 days to resolve.