BCBS North Carolina coverage for Wegovy (Weight Loss)

Patient must have anti-obesity medication coverage benefits (criterion 7 of initial criteria; criterion 4 of continuation criteria)

What you need to qualify

• Age 12 and older
• BMI of 30 or higher
• BMI of 27 or higher with a weight-related condition (CVD, CAD, HTN, OSA, knee_osteoarthritis, T2DM, dyslipidemia, PCOS, NASH/NAFLD, asthma, and COPD)
• BMI of 25 or higher for patients of Asian descent
• 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.

Documentation to bring

• Baseline BMI documentation
• Documentation of obesity diagnosis or weight-related comorbidity
• For Asian descent patients: documentation of ancestry (South Asian, Southeast Asian, or East Asian)
• Documentation that provider addressed lifestyle modification requirement (calorie restriction and increased physical activity)
• Documentation of 6-month lifestyle modification attempt with failure to achieve 1 lb/week weight loss, OR documentation of weight-related comorbidity warranting immediate medication intervention
• Documentation that patient is not concurrently using another GLP-1 receptor agonist
• Documentation that patient is not concurrently using another weight loss medication
• Confirmation of anti-obesity medication coverage benefits
• For pediatric patients (12-17): documentation of BMI > 95th percentile for age and sex

Quantity limits

• 0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 4 pens per 28 days
• 1.5 mg tablet — 1 tablet per day
• 4 mg tablet — 1 tablet per day
• 9 mg tablet — 1 tablet per day

Approval and renewal

• Initial approval: 6 months
• Renewal: every 12 months
• To renew, the plan looks for at least 5% weight loss from the starting weight, at least 5% reduction in BMI, and Adults: weight loss >= 5% from baseline (prior to initiation). Ages 12-17: BMI reduction >= 5% from baseline. Patient must retain anti-obesity medication coverage benefits. Initial BMI, lifestyle, and comorbidity criteria are not re-verified at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Concurrent use of another GLP-1 receptor agonist
• Concurrent use of another weight loss medication
• Non-formulary products require Non-formulary Exception Criteria

Policy note: Policy covers Wegovy injection (0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg), Wegovy HD injection (7.2mg), and Wegovy tablets under one policy. This entry covers injection (standard doses) and tablets for weight loss indication. Quantity limits listed only apply to doses with explicit QL; maintenance doses (1.7mg, 2.4mg) do not have a listed quantity limit per May 2024 update. Quantity limit exception criteria allows a 90-day titration period override. Policy name is 'Anti-Obesity Agents – NC Standard'. Reviewed by Blue Cross NC P&T Committee annually in Q1.

Policy effective July 1, 2026 · verified July 16, 2026 · source: Pa policy