Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 18 and older
- BMI of 35 or higher
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Adult weight loss - initial approval
All of:
- Age 18 years or older
- Baseline BMI >= 35 kg/m2
- Participated in comprehensive weight management program (behavioral modification, reduced-calorie diet, increased physical activity) with continuing follow-up for at least 6 months prior to drug therapy
- Used with reduced-calorie diet AND increased physical activity
- Request is NOT for Wegovy HD 7.2 mg injection OR Wegovy tablets (injection only for adult weight loss criteria)
Documentation to bring
- Baseline BMI documentation (>= 35 kg/m2)
- Documentation of participation in a comprehensive weight management program for at least 6 months prior to drug therapy
Quantity limits
- 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
- 1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens each) / 63 days (84-day)
Approval and renewal
- Initial approval: 8 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, Patient must have completed at least 3 months of therapy at a stable maintenance dose AND lost at least 5% of baseline body weight OR maintained initial 5% weight loss. Baseline BMI >= 35 is re-verified at continuation, and at least 12 weeks on therapy before the first renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Wegovy HD 7.2 mg injection is excluded from adult weight loss criteria under this policy section (has its own separate criteria)
- Wegovy tablets are excluded from this specific adult weight loss injection criteria section (tablets have separate DOA)
Policy note: This policy is specifically titled 'BMI 35' and requires a baseline BMI >= 35 kg/m2 for adult weight loss (higher than the FDA label threshold of >= 27 with comorbidity or >= 30). Wegovy HD 7.2 mg injection has a separate DOA entry (Initial: 8 months, Continuation: 12 months) but its criteria are not separately detailed — it appears to follow the same adult weight loss criteria. Wegovy tablets have an Initial DOA of 6 months and Continuation DOA of 12 months. Concomitant use with other semaglutide-containing products or other GLP-1 receptor agonists is not recommended.
Policy effective April 10, 2026 · verified June 2, 2026 · source: policy-260.html