Applies to Employer plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
Adult obesity - BMI ≥ 30
All of:
- Adult patient with initial BMI ≥ 30 kg/m2
- 6-month trial of comprehensive weight loss plan (reduced calorie diet, increased physical activity, behavioral modifications) prior to initiation
- Member will use medication as adjunct to comprehensive weight management plan
Adult obesity - BMI ≥ 27 with comorbidity
All of:
- Adult patient with initial BMI ≥ 27 kg/m2
- At least one weight-related comorbid condition (hypertension, dyslipidemia, type 2 diabetes)
- 6-month trial of comprehensive weight loss plan (reduced calorie diet, increased physical activity, behavioral modifications) prior to initiation
- Member will use medication as adjunct to comprehensive weight management plan
Pediatric obesity (subcutaneous Wegovy only, ages 12-17)
All of:
- Patient is 12 through 17 years of age
- Initial BMI at 95th percentile or greater standardized for age and gender
- Documentation includes baseline BMI, baseline weight, and BMI percentile
- 6-month trial of comprehensive weight loss plan (reduced calorie diet, increased physical activity, behavioral modifications) prior to initiation
- Member will use medication as adjunct to comprehensive weight management plan
Documentation to bring
- Baseline BMI documentation
- For adults: BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with documentation of at least one weight-related comorbidity (hypertension, dyslipidemia, type 2 diabetes)
- For pediatric patients (subcutaneous Wegovy only): baseline BMI, baseline weight, and BMI percentile documenting ≥ 95th percentile for age and sex
- Physician attestation or documentation of completed 6-month comprehensive weight loss program (reduced calorie diet, increased physical activity, behavioral modifications) prior to initiation
- Physician attestation that member will use medication as adjunct to comprehensive weight management plan
- Chart notes or lab results supporting medical necessity
- For continuation: documentation of weight loss ≥ 5% of baseline body weight within first 16 weeks OR continued weight loss OR maintained plateau weight
- For continuation: documentation of adherence to and tolerance of recommended maintenance dose for at least 3 consecutive months
- For continuation: documentation of ongoing comprehensive weight management plan
Quantity limits
- all strengths — 1-month supply (28 to 30 days); 75% of days must be exhausted before refill
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- Renewal: Must meet ONE of: (a) documented weight loss of at least 5% of baseline body weight after first 16 weeks of treatment; OR (b) demonstrated continued weight loss; OR (c) maintaining plateau weight achieved with diet/exercise. Patient must also be adherent and tolerating recommended maintenance dose for at least 3 consecutive months, and continue with comprehensive weight management plan.
- Renewal: Staying on a maintenance dose of at least 1.7 mg.
Not covered when
- Mail order pharmacy benefit excluded
- Members with BCBSMA Focused Formulary: GLP-1/GLP-1/GIP medications are not a covered benefit effective 1/1/2026
- Wegovy HD (high dose) and Wegovy oral tablet are only FDA approved for adults — pediatric weight loss indication applies to subcutaneous Wegovy only
- Requests based exclusively on use of samples will not meet coverage criteria
Policy note: Wegovy injection maintenance doses for adults include 1.7 mg, 2.4 mg, or 7.2 mg; for patients 12-17 years include 1.7 mg or 2.4 mg. Wegovy oral tablet maintenance dose is 25 mg. Wegovy HD is NOT FDA approved for MASH or CV risk reduction. Policy applies to Commercial members (HMO/POS, PPO/EPO, Indemnity, MEDEX with Rx, Managed Blue for Seniors) but NOT Medicare Advantage. All GLP-1 prescriptions excluded from mail order pharmacy benefit. For non-covered medications, member must have had previous treatment failure with or contraindication to at least two covered formulary alternatives.
Policy effective May 1, 2026 · verified June 2, 2026 · source: 572%20 GLP-1%20and%20 GLP-1%20 %20 Gip%20 Agonist%20 Drugs%20for%20 Anti Obesity%20 Management%20and%20 Other%20 Non Obesity%20 Conditions · View policy document (PDF)