Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (hypertension, T2DM, OSA, CVD, and dyslipidemia)
- 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.
Adult weight management (BMI >= 30)
All of:
- Patient is an adult (18 years of age or over)
- BMI >= 30 kg/m^2
- Obesity is NOT restricted from coverage under the patient's benefit
- Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
- Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
- Patient will NOT use the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
- Age is within FDA labeling for the requested indication OR there is support for use at patient's age
Plus any one of:
- Patient has NOT tried a targeted weight loss agent (e.g., Saxenda, Wegovy, Zepbound) in the past 12 months
- Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy
Adult weight management (BMI >= 25 - Asian descent)
All of:
- Patient is an adult (18 years of age or over)
- Patient is of South Asian, Southeast Asian, or East Asian descent
- BMI >= 25 kg/m^2
- Obesity is NOT restricted from coverage under the patient's benefit
- Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
- Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
- Patient will NOT use the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
- Age is within FDA labeling for the requested indication OR there is support for use at patient's age
Plus any one of:
- Patient has NOT tried a targeted weight loss agent (e.g., Saxenda, Wegovy, Zepbound) in the past 12 months
- Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy
Adult weight management (BMI >= 27 with comorbidity)
All of:
- Patient is an adult (18 years of age or over)
- BMI >= 27 kg/m^2
- At least one weight-related comorbidity/risk factor/complication (e.g., hypertension, type 2 diabetes mellitus, obstructive sleep apnea, cardiovascular disease, dyslipidemia)
- Obesity is NOT restricted from coverage under the patient's benefit
- Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
- Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
- Patient will NOT use the requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
- Age is within FDA labeling for the requested indication OR there is support for use at patient's age
Plus any one of:
- Patient has NOT tried a targeted weight loss agent (e.g., Saxenda, Wegovy, Zepbound) in the past 12 months
- Patient tried a targeted weight loss agent for a previous course of therapy in the past 12 months AND prescriber anticipates success with repeating therapy
Pediatric weight management (age 12-17, BMI >= 95th percentile or >= 30)
All of:
- Patient is pediatric (12 to 17 years of age)
- Obesity is NOT restricted from coverage under the patient's benefit
- Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
- Patient has been on a weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months
- Patient will NOT use the requested agent in combination with another weight loss agent
- Patient will NOT use the requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications to the requested agent
- Patient is currently on a weight loss regimen of a low-calorie diet, increased physical activity, and behavioral modifications AND will continue it
- Age is within FDA labeling for the requested indication OR there is support for use at patient's age
Plus any one of:
- BMI >= 95th percentile for age and sex
- BMI >= 30 kg/m^2
- BMI >= 85th percentile for age and sex AND at least one weight-related comorbidity/risk factor/complication (e.g., hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea)
Documentation to bring
- Documentation of BMI >= 30 kg/m^2 (or >= 27 with comorbidity, or >= 25 if Asian descent, or BMI percentile for pediatric patients)
- Documentation of 6-month weight loss regimen (low-calorie diet, increased physical activity, behavioral modifications)
- Documentation of weight-related comorbidity if using the 27 kg/m^2 threshold
- Documentation of ancestry if using the 25 kg/m^2 Asian threshold
- Documentation that obesity is not restricted from coverage under the patient's benefit
Quantity limits
- 1.5 MG tab, 4 MG tab, 9 MG tab — 60 Tablets per 180 days (84-day)
- 25 MG tab — 30 Tablets per 30 days
- 0.25 MG/0.5 ML injection, 0.5 MG/0.5 ML injection, 1 MG/0.5 ML injection — 8 Pens per 180 days (84-day)
- 1.7 MG/0.75 ML injection, 2.4 MG/0.75 ML injection — 4 Pens per 28 days
- 7.2 MG/0.75 ML injection (Wegovy hd) — 4 Pens per 28 days
Approval and renewal
- Initial approval: 12 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, For renewal (after 52 weeks), adult patients must have achieved and maintained >= 5% weight loss from baseline, OR pediatric patients must have achieved and maintained >= 5% BMI reduction from baseline. Patients with < 52 weeks on therapy on maximum-tolerated dose may also qualify. Renewal also requires: obesity not restricted from benefit, continuing current weight loss course of therapy, pediatric patients (12-17) must have current BMI >= 85th percentile for age and sex, not combining with another weight loss agent, maintaining low-calorie diet/increased physical activity/behavioral modifications, not combining with another GLP-1 agonist, and no FDA labeled contraindications, and at least 52 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
- Combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical) not allowed
- Combination with another GLP-1 receptor agonist (e.g., Saxenda, Wegovy, Zepbound, Bydureon, Byetta, Mounjaro, Ozempic, Rybelsus, Trulicity, Victoza) not allowed
- Any FDA labeled contraindications to the requested agent
- Obesity restricted from coverage under the patient's benefit
Policy note: Policy applies to Wegovy injection (subcutaneous) and Wegovy tablets. Quantity limit criteria allow exceptions for maintenance on lower doses if patient is unable to use FDA-labeled maintenance strength and has achieved weight loss on the lower strength. For continuation after 52 weeks on maximum-tolerated dose, patient must demonstrate >= 5% weight loss (adult) or >= 5% BMI reduction (pediatric). Patients with < 52 weeks on maximum-tolerated dose may qualify for renewal without demonstrating weight loss. Policy also allows approval if patient has another FDA labeled indication for the requested agent.
Policy effective June 1, 2026 · verified June 4, 2026 · source: WY_Weight_Management_PAQL_ProgSum.pdf