How to Read a Formulary for GLP-1s: Tiers, PA, ST and QL Decoded

To read a formulary for a GLP-1, get the drug list for your exact plan and plan year. Search it by brand and generic name, then read the three things printed on that drug's row: the tier (your cost level), the letters (PA, ST, QL and other rules) and any footnotes. If the drug isn't there at all, check whether your plan has a separate excluded-drugs list.

The formulary is the PDF you get from your benefits portal. It's 140 pages long, the font is tiny, and the first word it uses for your medicine is "semaglutide." Here's how to decode it.

What is a formulary, in plain English?

HealthCare.gov defines a formulary as "a list of prescription drugs covered by a prescription drug plan," also called a drug list. Medicare.gov adds that plans pick which drugs they cover and sort them into cost tiers. Two people with insurance from the same company can have completely different formularies, because the employer or plan sponsor chooses the version.

So step zero is finding your document:

• Employer plan: Look in your benefits portal or on your pharmacy benefit manager's (PBM's) website under something like "drug list," "formulary" or "covered medications." Match the plan name and the year.
• Medicare Part D or Medicare Advantage: Use Medicare Plan Finder at medicare.gov/plan-compare. You enter your drugs and see which plans cover them. Your plan's own site also has the full formulary.
• Marketplace plan: Each plan links to its drug list. Make sure it's the one for the plan level you're looking at, not the insurer's generic list.

Look at the date on the cover. A 2026 list won't tell you what happens on January 1, 2027.

How do you search a formulary PDF for a GLP-1?

Use Ctrl+F (Cmd+F on a Mac), but search smart.

1. Search the brand name: Wegovy, Ozempic, Rybelsus, Zepbound, Mounjaro, Saxenda, Victoza, Trulicity, Foundayo.
2. Then search the generic name: semaglutide, tirzepatide, liraglutide, dulaglutide, orforglipron. Some lists sort by generic name, or put the brand in capital letters next to it.
3. Don't search "GLP-1." Drug lists organize medicines by therapeutic category, and the label varies by plan. You might see diabetes drugs under something like "blood glucose regulators," with weight-management drugs in their own section.
4. No hits for anything? The PDF may be a scanned image. Go to the alphabetical index at the back and look up the page by hand.
5. Look at every match. Semaglutide can appear more than once, for example Ozempic in one section and Wegovy in another, with different tiers and rules for each.

What do the tier numbers mean?

Tiers tell you roughly what you'll pay, from cheapest to most expensive. Medicare.gov gives this example, and many plans use something similar:

Tier	What it usually holds	Your cost
Tier 1	Mostly generics	Lowest copay
Tier 2	Preferred brand-name drugs	Medium copay
Tier 3	Non-preferred brand-name drugs	Higher copay
Specialty tier	Very high-cost drugs	Highest copay or coinsurance

There are no generic versions of the branded GLP-1s in this article, so expect to see them on a brand tier. That might be preferred brand, non-preferred brand or specialty, depending on the plan. Your plan may number its tiers differently, which is why the cost table in your plan documents matters more than the tier number itself.

The tier also doesn't tell you the price at the counter if you're still in your deductible. A tier-2 drug can cost the full negotiated price until you meet it. Our post on "covered" vs "affordable" has worked examples.

What do PA, ST and QL mean on a drug list?

These letters are the rules attached to coverage. Medicare.gov describes the three you'll see most:

• PA (prior authorization): Your prescriber has to show the plan the drug is medically necessary before it pays. For a GLP-1, the plan's criteria often look at your diagnosis, for example type 2 diabetes vs weight management, and sometimes at BMI or other conditions.
• ST (step therapy): You first try a less expensive drug on the list before the plan covers the more expensive one. Medicare.gov calls it a kind of prior authorization.
• QL (quantity limit): The plan caps how much it covers over a set period. Medicare.gov's example is "30 tablets of a drug per month." For injectable pens, a QL often shows up as a set number of pens or milliliters per 28 days.

Your PDF will have a legend or key page, usually near the front, that defines every abbreviation it uses. Plans add their own codes (for mail-order availability, limited-access drugs, Part B vs Part D, and so on), so read your legend before guessing.

A made-up example row:

SEMAGLUTIDE (WEGOVY) 2.4 MG/0.75 ML PEN — Tier 3 — PA; QL (4 pens per 28 days)

How to read it: it's covered, at a non-preferred brand cost level, but only after your prescriber gets approval, and only up to one box of pens per 28 days. If you see "PA," the next step is our prior authorization paperwork checklist.

What if your GLP-1 isn't on the formulary at all?

Not finding it can mean a few different things:

• It's on a separate excluded-drugs list. Many commercial plans publish exclusions in their own document. These lists change. CVS Caremark, for example, removed Zepbound from its commercial template formularies on July 1, 2025, in favor of Wegovy. In May 2026 it announced that Zepbound would come back as an additional preferred option on October 1, 2026. Employers that use those template formularies can still customize them, so the PBM's announcement isn't your answer. Your plan's document is.
• Your plan excludes weight-management drugs as a category. The same molecule may still be covered for diabetes. KFF notes that Medicare is barred by law from covering drugs used specifically for obesity. Part D plans can cover Wegovy for its cardiovascular indication, Zepbound for sleep apnea and many GLP-1s for type 2 diabetes. The temporary Medicare GLP-1 Bridge runs outside the formulary for weight management.
• You searched the wrong year or plan. It happens more than anyone admits.

Can you ask for an exception?

Yes. In Medicare, a coverage exception asks the plan to cover a drug that isn't on its list or to waive a rule like a QL. A tiering exception asks for a lower cost-sharing level. Your prescriber has to send a statement explaining the medical reason. Commercial plans have their own exception and appeal processes, and the plan documents tell you how. If you get a denial, start with how to organize an appeal.

Formulary notes worth saving

Plans can change their drug lists, and Medicare plans must tell you about changes that affect drugs you're taking. Keep a small record:

What to save	Example
Plan name and year	"Acme Gold PPO, 2026"
Document date or version	"Updated 09/01/2026"
Drug name exactly as listed	"Tirzepatide (Zepbound) KwikPen"
Tier and codes	"Tier 3, PA, QL"
Footnote text	Copied word for word
Date you checked	"Oct 27"

If you're choosing a plan this fall, do this check before you enroll. Our open enrollment questions post has the rest of the list.

Common questions

Why is my GLP-1 on the formulary but my claim was rejected?

Being on the list means the plan can cover it, not that it will automatically pay. A PA, ST or QL code, or a footnote limiting the covered diagnosis, can still block the claim until those rules are met.

Which tier are Wegovy, Zepbound and Ozempic usually on?

It varies by plan. Branded GLP-1s don't have generics, so they usually sit on a preferred brand, non-preferred brand or specialty tier. Your plan's own drug list is the only reliable answer.

Is a formulary the same for every plan from one insurer?

No. Insurers and PBMs often offer several formularies, and employers can customize them. Always match the document to your specific plan name and plan year.

How often do formularies change?

Most change at the start of each plan year, and plans can also change them during the year under their rules. Medicare plans must notify you about changes that affect a drug you take. Check again at renewal and whenever a refill unexpectedly costs more.