Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 12 to 17
- BMI at or above the 95th percentile for age and sex
- 6 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Pediatric Weight Loss (ages 12-17) - Obesity
All of:
- Patient is 12 to 17 years of age
- Request is NOT for Wegovy HD 7.2 mg injection OR Wegovy tablets
- Participated in a 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
- Baseline BMI >= 95th percentile standardized for age and sex (obesity) (if transitioning, use BMI at start of any drug therapy)
- Used with a reduced-calorie diet AND increased physical activity
Documentation to bring
- Baseline BMI documentation at or above the 95th percentile standardized for age and sex (if transitioning from another weight loss drug, BMI at start of any drug therapy)
- Documentation of BMI reduction from baseline or maintenance of initial BMI reduction (for continuation)
Quantity limits
- 0.25mg/0.5mL, 0.5mg/0.5mL, 1mg/0.5mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens each) / 63 days (84-day)
- 1.7mg/0.75mL, 2.4mg/0.75mL — 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: 7 months
- Renewal: every 12 months
- To renew, the plan looks for Patient must have successfully titrated to a stable maintenance dose AND had a reduction from baseline BMI OR continued to maintain their initial BMI reduction. Documentation required. Note: initial 6-month lifestyle program requirement and BMI percentile threshold are not re-verified at continuation.
Not covered when
- Wegovy HD 7.2 mg injection is excluded for pediatric patients (ages 12-17)
- Wegovy tablets are excluded for pediatric patients (ages 12-17)
- Concomitant use with other semaglutide-containing products is not recommended
- Concomitant use with any other GLP-1 receptor agonist is not recommended
Policy note: This entry covers the pediatric weight loss indication only (ages 12-17), which is restricted to Wegovy injection (excluding HD 7.2 mg) and excludes tablets. Continuation requires successful titration to stable maintenance dose and BMI reduction or maintenance.
verified June 2, 2026 · source: 4774-C_Wegovy.pdf