The FDA label criteria, your insurance plan's rules, and a clinician's assessment are three independent gates. You can meet one and not the others. We check all three before any prescription is written.
Label, insurance, and clinical fit are separate decisions
Label eligibility is the FDA's criteria: BMI thresholds and the diagnoses that lower them. It is the easiest to verify because it is a number and a list. Most people who ask meet this one.
Insurance eligibility is your plan's separate rules. Many plans require prior authorisation, documented previous diet attempts, or exclude weight-management drugs entirely. Meeting the label criteria does not guarantee funding.
Clinical appropriateness is the clinician's assessment of you: your medical history, all your medications, and whether the risks are acceptable in your case. This can override both the others. Learn more about BMI thresholds, conditions that qualify, and insurance coverage.
Three gates
The screening process
How we assess eligibility, step by step
Calculate your BMI
Height and weight give the starting number. It is a crude measure and only the entry gate, but it is where the process begins.
Review your diagnoses
Prediabetes, type 2 diabetes, high blood pressure, high cholesterol and sleep apnea each lower the BMI threshold. Any documented condition matters.
Check your medications
Everything you take, including prescriptions from other specialists. Drug interactions are the most common reason a plan needs adjustment or a prescription is declined.
Make a decision
Either you are a candidate and next steps are explained, or you are not and you are told exactly why.
Red flags in screening
A real assessment always asks these questions
If nobody asks about family history of thyroid cancer, personal history of pancreatitis or gallbladder disease, or whether you could be pregnant, that is not a fast service. It is an incomplete one. These are not optional questions.
The same applies to a prescription issued without a full medication review. Interactions with diabetes drugs are the most common reason plans deny coverage or clinicians decline to prescribe. The detail is in contraindications, medication interactions, and supervised care.
Family and personal historyAlways asked
Your full medication listAlways read
Pregnancy screeningNever skipped
Eligibility resources
Understand the qualification criteria
Thresholds, qualifying conditions, exclusions and where to start.
The thresholds, what happens if you do not meet them, and who decides.
The free eligibility check. It takes about two minutes, covers BMI, conditions and current medications, and needs no card. It screens rather than decides, and it tells you whether a consultation is worth booking.
Yes, at 27 and above where a weight-related condition is documented. Prediabetes, type 2 diabetes, high blood pressure, high cholesterol and sleep apnea are the ones that come up most often.
No. Meeting the criteria makes you a candidate for assessment. The clinical decision comes after your history and medications have been reviewed, and it can go either way.
You are told why, and what is reasonable instead. That might be nutrition support and monitoring, or investigating something that has not been looked at. It is not simply a refusal.
Not negatively. It is useful information, and some insurers actually require documented previous attempts before they will fund treatment, so it can help rather than hinder.
The three-way split between what the label says, what my insurer pays and what the doctor thinks was explained in five minutes. Nobody had done that before.
Q. Baptiste
Eligibility, Orlando
★★★★★
Assumed I was under the line. My prediabetes diagnosis meant I was not, which I only found out by asking.
Z. Ionescu
Qualified at 28, Tampa
★★★★
They asked about a family thyroid history I had forgotten about entirely. It changed the plan and I am glad they asked.
U. Kimani
Screening, Daytona Beach
★★★★★
Did not qualify and was told plainly why, with something else to try. Better than a prescription from someone who never looked.
