The insurer's determination that a treatment is required to diagnose or treat a condition, often required for coverage approval.
Updated Sep 26, 2026
Medical necessity is the standard insurers use to decide whether a treatment is appropriate and required for a patient's diagnosis. Many insurers require documentation of medical necessity — such as a qualifying BMI or a related condition like type 2 diabetes — before approving coverage for GLP-1 medications, especially for weight management rather than diabetes.
HealthCare.gov defines medically necessary care as services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms that meet accepted standards of medicine (HealthCare.gov ↗ (external link)).
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Related terms
Semaglutide salt forms — Versions of semaglutide such as semaglutide sodium and semaglutide acetate, which the FDA says are different active ingredients from the semaglutide base used in approved drugs, with no known lawful basis for compounding.
Open enrollment — The annual window when you can enroll in or change your health plan, and the time to compare GLP-1 coverage across the plans available to you.
P&T committee (Pharmacy and Therapeutics committee) — The panel of physicians, pharmacists, and other clinicians that reviews the clinical evidence behind a plan's formulary: which drugs are acceptable, which are interchangeable, and what restrictions apply.
API (active pharmaceutical ingredient) — The raw drug substance in a medication that produces its effect — for example, semaglutide itself, before it is formulated into a pen or vial.
Certificate of analysis (CoA) — A document reporting the lab test results for a specific batch of a drug ingredient or product, such as identity, purity, and contaminants.
Related guides
Applying for a GLP-1 patient assistance program: step by step — Novo Nordisk's PAP and Lilly Cares can provide Ozempic or Trulicity free to people who qualify by income and insurance status, but as of September 2026 neither covers Wegovy, Zepbound, Saxenda, or Foundayo. Here's who qualifies, the 2026 income limits in dollars, the documents you need, your prescriber's role, turnaround and renewal, what to do if you're denied, and how PAPs differ from savings cards and direct-pay.