Is Wegovy Covered by Insurance? Coverage Tips
Getting Wegovy approved through your insurance plan can feel like navigating a maze. While some policies cover it for weight loss or diabetes-related obesity, many require prior authorization or deny coverage altogether. This guide will walk you through what to expect, who’s more likely to get approval, and what to do if you’re denied.
Quick Insights: Wegovy Insurance Coverage in 2025
- Wegovy is often covered for obesity or diabetes, but requires prior authorization.
- Medicare Part D does not typically cover Wegovy unless tied to another condition like diabetes.
- Employer-based and ACA plans may include Wegovy under preventive care if BMI >30.
- If denied, appeal options and discount programs like GoodRx or NovoCare exist.
- State Medicaid coverage for Wegovy varies—check local formularies.
What Is Wegovy and How Does It Work?
Wegovy is a GLP-1 receptor agonist (semaglutide) that mimics hormones to suppress appetite and reduce body weight. Approved by the FDA in 2021, it’s typically prescribed for individuals with a BMI of 30+ or 27+ with related conditions like Type 2 diabetes or high blood pressure.
When Is Wegovy Covered by Insurance?
Insurance plans may cover Wegovy if you meet certain clinical guidelines:
- BMI ≥30, or ≥27 with coexisting conditions
- Prior use of other weight loss strategies (documented)
- Physician documentation supporting medical necessity
Most plans require a prior authorization form, often reviewed by a pharmacy benefit manager (PBM) like CVS Caremark or OptumRx.
How Do I Check if Wegovy Is Covered by My Insurance?
Start by:
- Logging into your insurer’s portal (e.g., Aetna, Cigna)
- Searching the formulary for “semaglutide” or “Wegovy”
- Reviewing notes about step therapy or prior authorization
- Calling the customer service line for confirmation
You can also ask your provider to submit a coverage determination form.
Which Insurance Plans Cover Wegovy in 2025?
| Insurer | Covered? | Prior Auth? | Notes |
|---|---|---|---|
| Aetna | Yes | Often | Varies by employer group plan |
| Blue Cross Blue Shield | Sometimes | Yes | Some plans exclude obesity meds |
| UnitedHealthcare | Yes | Yes | Approval depends on diagnosis |
| Cigna | Yes | Likely | May require clinical notes |
| Medicare Part D | Rarely | N/A | Limited obesity drug coverage |
| Medicaid (varies by state) | Sometimes | Yes | Check local rules |
How Does Formulary Tier Placement Affect Wegovy Costs?
If Wegovy is on Tier 3 or Tier 4, you’ll likely face higher copays or coinsurance. Tier 1 drugs are generics; Tier 2 are preferred brands. Tier 3 and higher often require prior auth and can cost hundreds monthly.
PBM Influence – How Caremark, OptumRx Differ on Wegovy
PBMs control formulary placement. OptumRx may list Wegovy as non-preferred; Caremark might allow Tier 3 access with PA. Check member formulary search tools for clarity.
Why Might Wegovy Not Be Covered?
Common reasons include:
- Obesity not listed as a covered diagnosis
- Your plan excludes weight-loss medications
- Prior authorization was incomplete
- Medication not on formulary
- Generic alternatives required first
Expert Tips for Getting Wegovy Approved
- Get your doctor to submit progress notes and previous weight management attempts.
- Use the exact medical codes your insurer’s PBM requires.
- Call your insurer and ask for the pharmacy department—not general customer service.
What to Do If Wegovy Is Not Covered by Insurance
You have options:
- File an appeal with medical records and BMI history
- Ask your doctor to re-submit with new ICD-10 codes
- Request a formulary exception
- Use NovoCare’s $25 copay card or GoodRx
- Consider alternatives like compounded semaglutide (if allowed)
Does Wegovy Require Step Therapy Under Your Plan?
Step therapy is a common insurance requirement where you must try and fail on less expensive treatments before moving to higher-cost drugs like Wegovy. For example, a typical sequence might require starting with phentermine, then moving to Saxenda or Qsymia, and only after documented failure or intolerance, allow Wegovy. This ensures insurers limit costs and prioritize older, less expensive medications first. Many insurers enforce step therapy protocols, typically starting with drugs like phentermine, orlistat, or Contrave.
What ICD-10 Codes Help Get Wegovy Covered?
ICD-10 codes like E66.01 (morbid obesity due to excess calories) or E66.9 (obesity, unspecified) are often necessary for prior authorization. These codes inform insurers that the medication is being prescribed for a covered medical condition, improving the likelihood of approval. Using precise and accurate codes demonstrates medical necessity. For a full list and description, see ICD10Data.com – Obesity Codes. Including secondary diagnoses like E11.9 (Type 2 diabetes) can improve approval odds.
Can a Doctor Override a Formulary Denial?
Yes. Physicians can submit a “formulary exception” with clinical justification. Success often depends on documented past failures, BMI history, and medical necessity.
How to Write a Successful Insurance Appeal Letter
Include:
- Member name, DOB, plan number
- Diagnosis with ICD-10 code
- Prior treatment attempts
- Explanation of medical necessity
- Provider signature and contact info
Letter of Medical Necessity Tips from Doctors
- Use precise ICD-10 codes
- Detail comorbidities (diabetes, hypertension)
- Reference past weight loss failures
- Keep tone clinical and assertive
How Prior Bariatric Surgery Affects Coverage
If a patient has had gastric bypass or sleeve, insurers may view Wegovy as unnecessary unless there’s evidence of weight regain or failed maintenance.
Case Example: How a Teacher Got Coverage via UMR
A 42-year-old public school teacher in Texas was denied Wegovy under her UMR plan due to lack of prior documented weight loss attempts. After submitting three months of diet logs and a letter from her endocrinologist, she gained approval—highlighting the importance of documentation.
Cost-Saving Strategies & Alternatives
Is Compounded Semaglutide an Option if Wegovy Is Denied?
Yes, some physicians prescribe compounded semaglutide from compounding pharmacies. However, compounded versions are not FDA-approved and may vary significantly in dosage and quality. In 2023, the FDA issued warnings about unregulated compounded GLP-1 products, citing risks of contamination and improper formulation. These versions are often used when commercial supplies are limited or insurance coverage is denied, but they carry clinical and legal uncertainties. Always verify pharmacy licensing and consult resources like FDA’s guidance on compounded GLP-1 medications. These may cost less but aren’t FDA-approved and may not be covered. Consult your provider and confirm legal status in your state.
Savings Program Deep Dive – Coverage Limits, Eligibility, Exclusions
NovoCare’s savings card may drop cost to $0, but caps savings at $225/month. The discount typically applies to 12 fills annually, subject to eligibility criteria. See full terms and conditions at NovoCare’s official savings page (https://www.novocare.com/obesity/products/wegovy/savings.html). It’s only for commercially insured, not government programs. Annual limits and eligibility renew yearly.
Financial Assistance Resources – State, Nonprofit, Pharma Grants
Look into:
- RxAssist.org (nonprofit directory)
- State-run drug assistance programs
- Novo Nordisk’s Patient Assistance Program (PAP)
Tax Savings – Can Wegovy Be Paid with HSA/FSA Accounts?
Yes—Wegovy qualifies as a prescription medication under IRS rules and can be paid with HSA or FSA funds, even if not covered by insurance.
Coverage Denied: Alternatives to Try First (Saxenda, Qsymia, etc.)
Many insurers want patients to try Saxenda, phentermine/topiramate (Qsymia), or orlistat before approving Wegovy. List these in prior auth paperwork.
Special Populations & Government Programs
Do Employer Plans Differ from ACA Marketplace Plans in Wegovy Access?
Yes. Employer-sponsored plans may have better coverage and more appeal options, while ACA plans vary by state and insurer. Formularies and prior auth processes may also differ.
Can Teens (12–17) Access Wegovy Under Medicaid?
Some states now approve Wegovy for youth with severe obesity under Medicaid, especially for ages 12+. Prior authorization is typically required, and usage must align with FDA indications.
What Wegovy Coverage Looks Like Under TRICARE or VA Plans
TRICARE and VA coverage is limited. The VA may prescribe Wegovy for diabetes but not for obesity alone. TRICARE often requires step therapy and military physician approval.
Medicare Nuance – Advantage vs Part D vs Medigap Plans
Medicare Advantage plans may cover Wegovy if medically necessary. Part D often excludes it unless it’s used for diabetes. Medigap does not cover prescriptions.
State-by-State Medicaid Comparison Chart
Here’s a sample state-by-state Medicaid comparison to help illustrate:
| State | Wegovy Covered | Age Limit | PA Required | Formulary Tier |
|---|---|---|---|---|
| California | Yes | 12+ | Yes | Tier 3 |
| Texas | No | N/A | N/A | Not listed |
| Florida | Yes | 18+ | Yes | Tier 4 |
| New York | Yes | 12+ | Yes | Tier 3 |
| Illinois | No | N/A | N/A | Not listed |
Note: This data reflects early 2025 formularies and may vary. Always check with your state Medicaid portal or PBM for the most accurate status.
FAQs
Can Specialists (Endocrinologists vs. PCPs) Increase Approval Odds?
Yes. Insurers often give more weight to prior auth requests from specialists like endocrinologists, bariatric physicians, or obesity medicine fellows.
How long does it take for insurance to approve Wegovy?
It typically takes 2 to 6 weeks, depending on how quickly your provider and insurer process the paperwork.
Is Wegovy covered by Medicare Advantage plans?
Some Medicare Advantage plans cover Wegovy if tied to obesity-related comorbidities. Original Medicare rarely does.
Can Wegovy be covered if prescribed for PCOS or prediabetes?
Possibly, but these off-label uses may require appeals with strong medical justification.
Does insurance cover Wegovy for teenagers?
Coverage is limited for those under 18, and usually requires specialist approval and extra documentation.
Are there cheaper alternatives if Wegovy isn’t covered?
Yes—Ozempic, Saxenda, or compounded semaglutide may be viable, but consult your physician first.
Conclusion
Understanding Wegovy coverage means knowing your insurer’s rules, gathering the right documentation, and being persistent. If you’re unsure whether your plan will approve it, speak with a licensed Hotaling insurance advisor to get help navigating prior authorizations and appeals.
Our benefits advisors help clients nationwide determine if Wegovy is covered under employer, ACA, or Medicare Advantage plans. Contact Hotaling Insurance Today →