Does BCBS Alabama cover Wegovy?

What you need to qualify

• Age 12 and older
• BMI of 30 or higher
• BMI of 27 or higher with a weight-related condition (HTN, T2DM, dyslipidemia, OSA, CVD, and MASH)
• BMI of 23 or higher for patients of Asian descent
• BMI at or above the 95th percentile for age and sex

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline BMI documentation meeting threshold (>= 30 kg/m2, or >= 27 kg/m2 with comorbidity, or >= 23 kg/m2 for qualifying Asian ethnicities)
• Documentation of qualifying weight-related comorbidity if BMI 27–29.9 kg/m2
• For pediatric patients: documentation of BMI >= 95th percentile for age/sex
• Documentation of reduced calorie diet and increased physical activity as adjunct

Approval and renewal

• To renew, the plan looks for at least 5% weight loss from the starting weight, At least 5% weight loss after 12 weeks at a therapeutic dose is required for continuation. Policy states efficacy should be assessed after 12 weeks at therapeutic dose, 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

• Concomitant use with other semaglutide-containing products not recommended
• Concomitant use with any other GLP-1 receptor agonist not recommended
• Pregnancy

Policy note: Policy covers both Wegovy subcutaneous injection and Wegovy tablet (oral semaglutide) formulations. Wegovy HD (higher-dose subcutaneous) is listed separately in FDA table but shares the same weight loss indication. Pediatric coverage (age >= 12) is noted in FDA labeling for subcutaneous injection. The 5% weight loss threshold at 12 weeks is cited from guidelines as the efficacy assessment standard.

Policy effective April 20, 2026 · verified June 2, 2026 · source: ALBP_Weight_Management_PAQL_ProgSum.pdf

What you need to qualify

• Age 12 and older
• BMI of 30 or higher
• BMI of 27 or higher with a weight-related condition (HTN, T2DM, dyslipidemia, OSA, CVD, and MASH)
• BMI of 23 or higher for patients of Asian descent
• BMI at or above the 95th percentile for age and sex

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline BMI documentation meeting threshold (>= 30 kg/m2, or >= 27 kg/m2 with comorbidity, or >= 23 kg/m2 for qualifying Asian ethnicities)
• Documentation of qualifying weight-related comorbidity if BMI 27–29.9 kg/m2
• For pediatric patients: documentation of BMI >= 95th percentile for age/sex
• Documentation of reduced calorie diet and increased physical activity as adjunct

Approval and renewal

• To renew, the plan looks for at least 5% weight loss from the starting weight, At least 5% weight loss after 12 weeks at a therapeutic dose is required for continuation. Policy states efficacy should be assessed after 12 weeks at therapeutic dose, 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

• Concomitant use with other semaglutide-containing products not recommended
• Concomitant use with any other GLP-1 receptor agonist not recommended
• Pregnancy

Policy note: Policy covers both Wegovy subcutaneous injection and Wegovy tablet (oral semaglutide) formulations. Wegovy HD (higher-dose subcutaneous) is listed separately in FDA table but shares the same weight loss indication. Pediatric coverage (age >= 12) is noted in FDA labeling for subcutaneous injection. The 5% weight loss threshold at 12 weeks is cited from guidelines as the efficacy assessment standard.

Policy effective April 20, 2026 · verified June 2, 2026 · source: ALBP_Weight_Management_PAQL_ProgSum.pdf

What you need to qualify

• Age 45 and older
• BMI of 27 or higher
• Established cardiovascular disease (CV death (qualifying history), non-fatal MI, and non-fatal stroke)
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of established cardiovascular disease (CV death history, non-fatal MI, non-fatal stroke, or equivalent)
• Baseline BMI documentation >= 27 kg/m2
• Confirmation of absence of diabetes diagnosis
• Age >= 45 years confirmed

Not covered when

• Patients WITH diabetes were excluded from the SELECT trial; CV indication inferred for non-diabetic patients only
• Concomitant use with other semaglutide-containing products not recommended
• Concomitant use with any other GLP-1 receptor agonist not recommended
• Pregnancy

Policy note: CV risk reduction indication supported by SELECT trial data (NCT03574597): semaglutide 2.4 mg reduced MACE by 20% vs placebo in patients >= 45 years with BMI >= 27 and established CVD WITHOUT diabetes. The policy document references this trial to support the indication. Age minimum of 45 is derived from SELECT trial enrollment criteria referenced in the document. The FDA label indication is for adults with established CV disease and obesity or overweight, but the document specifically references the non-diabetic population from SELECT.

Policy effective April 20, 2026 · verified June 2, 2026 · source: ALBP_Weight_Management_PAQL_ProgSum.pdf

What you need to qualify

• Age 45 and older
• BMI of 27 or higher
• Established cardiovascular disease (CV death (qualifying history), non-fatal MI, and non-fatal stroke)
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of established cardiovascular disease (CV death history, non-fatal MI, non-fatal stroke, or equivalent)
• Baseline BMI documentation >= 27 kg/m2
• Confirmation of absence of diabetes diagnosis
• Age >= 45 years confirmed

Not covered when

• Patients WITH diabetes were excluded from the SELECT trial; CV indication inferred for non-diabetic patients only
• Concomitant use with other semaglutide-containing products not recommended
• Concomitant use with any other GLP-1 receptor agonist not recommended
• Pregnancy

Policy note: CV risk reduction indication supported by SELECT trial data (NCT03574597): semaglutide 2.4 mg reduced MACE by 20% vs placebo in patients >= 45 years with BMI >= 27 and established CVD WITHOUT diabetes. The policy document references this trial to support the indication. Age minimum of 45 is derived from SELECT trial enrollment criteria referenced in the document. The FDA label indication is for adults with established CV disease and obesity or overweight, but the document specifically references the non-diabetic population from SELECT.

Policy effective April 20, 2026 · verified June 2, 2026 · source: ALBP_Weight_Management_PAQL_ProgSum.pdf

What you need to qualify

• Age 18 and older
• Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, MRE, ELF_test, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Diagnosis of noncirrhotic MASH (formerly NASH/MASLD)
• Confirmation of fibrosis stage F2 or F3 via non-invasive testing (FIB-4, ELF, VCTE/FibroScan, or MRE) or liver biopsy
• FIB-4 as primary risk stratification with secondary confirmatory elastography or ELF if FIB-4 is indeterminate
• Confirmation of absence of cirrhosis

Not covered when

• Cirrhotic MASH is excluded (FDA indication limited to noncirrhotic MASH)
• Concomitant use with other semaglutide-containing products not recommended
• Concomitant use with any other GLP-1 receptor agonist not recommended
• Pregnancy

Policy note: FDA indication for MASH is limited to Wegovy subcutaneous injection (not the tablet formulation listed separately). Fibrosis stage F2-F3 required per both FDA label and the NASH trial (NCT04822181) referenced in the document. The document outlines a two-step non-invasive testing approach: Step 1 FIB-4 (low risk < 1.30, indeterminate 1.30–2.67, high risk > 2.67; for patients > 65 years, higher cutoff > 2.0 for rule-in), Step 2 ELF and/or elastography (VCTE) with specific cutpoints referenced (ELF < 7.7 low risk, 7.7–9.8 intermediate, >= 9.8 high risk; VCTE < 8 kPa low risk, 8–12 kPa indeterminate, > 12 kPa high risk/advanced fibrosis). MRE also noted as an option. Lookback periods for testing are not explicitly specified in the PA criteria section of this document. Alcohol abstinence recommended in advanced fibrosis but no specific gram limits stated as PA criteria. This is a Program Summary document; specific PA approval criteria thresholds may be in a separate criteria document.

Policy effective April 20, 2026 · verified June 2, 2026 · source: ALBP_Weight_Management_PAQL_ProgSum.pdf

What you need to qualify

• Age 18 and older
• Confirmed MASH diagnosis by FIB-4, FibroScan_VCTE, MRE, ELF_test, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Diagnosis of noncirrhotic MASH (formerly NASH/MASLD)
• Confirmation of fibrosis stage F2 or F3 via non-invasive testing (FIB-4, ELF, VCTE/FibroScan, or MRE) or liver biopsy
• FIB-4 as primary risk stratification with secondary confirmatory elastography or ELF if FIB-4 is indeterminate
• Confirmation of absence of cirrhosis

Not covered when

• Cirrhotic MASH is excluded (FDA indication limited to noncirrhotic MASH)
• Concomitant use with other semaglutide-containing products not recommended
• Concomitant use with any other GLP-1 receptor agonist not recommended
• Pregnancy

Policy note: FDA indication for MASH is limited to Wegovy subcutaneous injection (not the tablet formulation listed separately). Fibrosis stage F2-F3 required per both FDA label and the NASH trial (NCT04822181) referenced in the document. The document outlines a two-step non-invasive testing approach: Step 1 FIB-4 (low risk < 1.30, indeterminate 1.30–2.67, high risk > 2.67; for patients > 65 years, higher cutoff > 2.0 for rule-in), Step 2 ELF and/or elastography (VCTE) with specific cutpoints referenced (ELF < 7.7 low risk, 7.7–9.8 intermediate, >= 9.8 high risk; VCTE < 8 kPa low risk, 8–12 kPa indeterminate, > 12 kPa high risk/advanced fibrosis). MRE also noted as an option. Lookback periods for testing are not explicitly specified in the PA criteria section of this document. Alcohol abstinence recommended in advanced fibrosis but no specific gram limits stated as PA criteria. This is a Program Summary document; specific PA approval criteria thresholds may be in a separate criteria document.

Policy effective April 20, 2026 · verified June 2, 2026 · source: ALBP_Weight_Management_PAQL_ProgSum.pdf