Applies to Employer and ACA Marketplace plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Adult - Obesity or Overweight with Comorbidity (Standard Pathway)
All of:
- Physician attestation of BMI ≥ 30 kg/m2 (obese) OR BMI ≥ 27 kg/m2 (overweight) with at least one weight-related comorbidity (hypertension, T2DM, or dyslipidemia)
- Current baseline weight documented
- Physician attestation that member will participate in lifestyle modifications (healthy eating, exercise if appropriate)
- Not to be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist-containing products
Adult - Alternative High-BMI Pathway via Teladoc Program
All of:
- Age ≥ 18 years old
- BMI ≥ 35 kg/m2
- Documentation of current (within 30 days) baseline weight
- Documentation of active participation for a minimum of 6 months in a lifestyle modification program (e.g., food diaries documenting caloric deficit or adherence to low calorie/modified diet, OR exercise logs/step counter reports/gym attendance logs/app/fitness tracker showing at least 10,000 steps/day or 150 min/week moderate-intensity activity)
- Documentation of current active participation in Teladoc Health Weight Management Program
- Must be prescribed by a PCP or provider with an established relationship with the member, who has seen the member in-person for evaluation and management of overall health
Pediatric - Ages 12 to 17
All of:
- Age 12 to 17 years
- BMI ≥ 95th percentile standardized for age and sex
- Current baseline weight documented
- Physician attestation that member will participate in lifestyle modifications (healthy eating, exercise if appropriate)
- Not to be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist-containing products
Documentation to bring
- Physician attestation of BMI (≥ 30 kg/m2 for obesity, or ≥ 27 kg/m2 with comorbidity, or ≥ 35 kg/m2 for alternative pathway)
- Documentation of current baseline weight
- Physician attestation of member participation in lifestyle modifications (healthy eating, exercise if appropriate)
- For alternative adult pathway: Documentation of at least 6 months of active participation in a lifestyle modification program (food diaries, exercise logs, step counter reports, gym logs, fitness tracker printouts showing 10,000 steps/day or 150 min/week moderate-intensity activity)
- For alternative adult pathway: Documentation of current active participation in Teladoc Health Weight Management Program
- For alternative adult pathway: Confirmation that prescriber is a PCP or established-relationship provider who has seen member in-person
- For pediatric: Documentation that BMI is ≥ 95th percentile standardized for age and sex
- Attestation that medication will not be combined with other weight loss products
- Attestation that medication will not be combined with other GLP-1 agonist-containing products
- For continuation (adults): Physician attestation that member maintains ≥ 5% weight loss from baseline
- For continuation (adults): Current weight submission
- For continuation (adults): Attestation of continued active participation in lifestyle modifications
- For continuation (adults): BMI ≥ 18.5 kg/m2
- For continuation (pediatrics): Physician attestation that member maintains ≥ 1% reduction in BMI from baseline
- For continuation (pediatrics): Current weight submission
- For continuation (pediatrics): Attestation of continued active participation in lifestyle modifications
- For continuation (pediatrics): BMI-for-age percentile ≥ 5th percentile
Approval and renewal
- Initial approval: 12 months
- Renewal: At least 5% weight loss from the starting weight.
- Renewal: At least 1% reduction in BMI.
- Renewal: For adults (obesity/overweight pathway): 5% weight loss from baseline, current weight submission, attestation of continued active participation in lifestyle modifications, BMI ≥ 18.5 kg/m2. For pediatrics (ages 12-17): 1% reduction in BMI from baseline, current weight submission, attestation of continued active participation in lifestyle modifications, BMI-for-age percentile ≥ 5th percentile. Initial BMI/comorbidity and other initial criteria are not explicitly re-verified at continuation.
Not covered when
- Cannot be used in combination with other weight loss products
- Cannot be used in combination with other GLP-1 agonist-containing products
Policy note: The document header states 'NC' (Not Covered) notation appears next to Wegovy and references that coverage criteria is 'determined by group benefit.' This suggests coverage is group-specific and not universally covered under all plans. The NC designation on the document header may indicate it is not covered for all members. Multiple qualification pathways exist including an alternative high-BMI pathway requiring Teladoc Health Weight Management Program participation. The document title states 'March 2019' but the revised date is 06-01-2026, indicating the effective date is June 2026.
Policy effective June 1, 2026 · verified June 2, 2026 · source: Prior Authorization And Step Therapy Guidelines · View policy document (PDF)