Centene

Does Centene cover Wegovy?

Quick answer · Weight Loss

Centene does not cover it for weight loss on ACA Marketplace.

  • ACA Marketplace: Not covered. Use of Wegovy for the treatment of weight management is a benefit exclusion and will not be authorized.

Last verified June 2, 2026. Policy effective June 1, 2024. Source: CP.PMN.295.pdf. How we verify this data →

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Wegovy for Weight Loss

What Centene requires, by plan type. Open this indication on its own page →

ACA Marketplace

Not covered

Use of Wegovy for the treatment of weight management is a benefit exclusion and will not be authorized.

Policy note: Explicitly stated as a benefit exclusion for both initial and continued therapy. This applies to the HIM/ICHRA and Medicaid lines of business covered by this policy. Note: Wegovy HD 7.2 mg formulation was added for weight management per the revision log (RT4, 03.24.26), but the policy text still states weight management is a benefit exclusion — this may reflect a pending update.

Policy effective June 1, 2024 · verified June 2, 2026 · source: CP.PMN.295.pdf

Wegovy for Heart Disease Risk Reduction

What Centene requires, by plan type. Open this indication on its own page →

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • 6 months of a documented diet and exercise program
  • Prior trial of 3 other GLP-1 medications (Ozempic, Rybelsus, Trulicity, and liraglutide (generic Victoza)) for at least 90 days
  • Established cardiovascular disease (MI, stroke, and PAD)
  • On guideline-directed medical therapy (statin, ezetimibe, fibrate, omega-3 fatty acids, PCSK9 inhibitor, ACE_inhibitor, ARB, calcium channel blocker, thiazide diuretic, beta_blocker, antiplatelet therapy, and antithrombotic therapy)

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction — No Concurrent T2DM

All of:

  • Established CVD: history of MI, history of stroke, or symptomatic PAD (ABI < 0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)
  • Age >= 18 years
  • BMI >= 27 kg/m2
  • Prescriber attestation of current cardiovascular standard of care management
  • Wegovy not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist
  • Active enrollment in physician-directed weight loss program for at least 6 months with plan to continue
  • Documentation of baseline body weight in kg
  • Dose within approved escalation schedule (up to 2.4 mg/week injection or 25 mg/day tablet)

CV Risk Reduction — With Concurrent T2DM

All of:

  • Established CVD: history of MI, history of stroke, or symptomatic PAD
  • Age >= 18 years
  • BMI >= 27 kg/m2
  • Prescriber attestation of current cardiovascular standard of care management
  • Wegovy not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist
  • Active enrollment in physician-directed weight loss program for at least 6 months with plan to continue
  • Documentation of baseline body weight in kg
  • Dose within approved escalation schedule
  • Trial of >= 3 consecutive months each of ALL of: Ozempic or Rybelsus, Trulicity, and liraglutide (generic Victoza), unless clinically significant adverse effects or all are contraindicated (Note: IL HIM requests exempt from step therapy as of 1/1/2026 per IL HB 5395)
  • If currently on a GLP-1 and switching to Wegovy: medical justification supports necessity (intolerance due to common GI adverse effects is NOT acceptable justification)

Documentation to bring

  • Office chart notes, lab results, or other clinical information supporting all approval criteria
  • Documentation of qualifying CVD event (history of MI, history of stroke, or symptomatic PAD with ABI < 0.85 / revascularization / amputation)
  • BMI documentation >= 27 kg/m2
  • Prescriber attestation that member is currently receiving cardiovascular standard of care management
  • Documentation of active enrollment in physician-directed weight loss program for at least 6 months
  • Documentation of member's baseline body weight in kg
  • For concurrent T2DM: documentation of >= 3-month trial each of Ozempic/Rybelsus, Trulicity, and liraglutide (generic Victoza) (unless adverse effects or all contraindicated), except IL HIM as of 1/1/2026
  • If switching from another GLP-1: medical justification supporting necessity for Wegovy specifically

Quantity limits

  • 0.25mg, 0.5mg, 1mg
  • 1.7mg, 2.4mg
  • 1.5mg tablet, 4mg tablet, 9mg tablet, 25mg 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, First renewal: must have lost >= 5% of baseline body weight. Second and subsequent renewals: must have lost weight and/or maintained weight loss. Maintenance dose >= 1.7 mg/week (injection) or 25 mg/day (tablet) required. GDMT requirement and lifestyle program enrollment re-verified at continuation. Prior GLP-1 step therapy NOT re-checked at continuation, and staying on a maintenance dose of at least 1.7 mg. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Concomitant use with other semaglutide-containing products
  • Concomitant use with any other GLP-1 receptor agonist
  • Personal or family history of medullary thyroid carcinoma (MTC) or MEN 2 (contraindication)
  • Known hypersensitivity to semaglutide or excipients

Exceptions

  • Illinois: Step therapy requirements for members with concurrent T2DM do not apply for Illinois HIM requests as of 1/1/2026 per IL HB 5395

Policy note: Symptomatic PAD defined per SELECT trial as intermittent claudication with ABI < 0.85 at rest, or peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease. Cardiovascular standard of care is broadly defined in Appendix D and includes condition-specific medications for dyslipidemia, hypertension, MI, stroke, and PAD. Wegovy tablets are approved only for CV event prevention indication (not MASH). Wegovy HD 7.2 mg injection formulation also available. IL HB 5395 exempts IL HIM requests from GLP-1 step therapy requirement for concurrent T2DM as of 1/1/2026.

Policy effective June 1, 2024 · verified June 2, 2026 · source: CP.PMN.295.pdf

Wegovy for Liver Disease (MASH)

What Centene requires, by plan type. Open this indication on its own page →

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • 6 months of a documented diet and exercise program
  • Prior trial of 3 other GLP-1 medications (Ozempic, Rybelsus, Trulicity, and liraglutide (generic Victoza)) for at least 90 days
  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by liver_biopsy, FIB-4, ELF_test, FibroScan_VCTE, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

MASH — No Concurrent T2DM

All of:

  • Diagnosis of MASH (formerly NASH)
  • Request is for Wegovy injection (not tablets)
  • Prescribed by or in consultation with a hepatologist or gastroenterologist
  • Age >= 18 years
  • MASH with stage F2 or F3 fibrosis confirmed by liver biopsy within last 3 years OR both a serum-based assessment (e.g., FIB-4, NFS, ELF) AND imaging-based assessment (e.g., VCTE, MRE, MRI-PDFF) within the last 6 months
  • Prescriber attestation of current standard of care management for concomitant related conditions (T2DM, dyslipidemia, hypertension)
  • Active enrollment in physician-directed weight loss program for at least 6 months with plan to continue
  • Wegovy not prescribed concurrently with Rezdiffra (resmetirom)
  • Wegovy not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist
  • Dose within approved escalation schedule (up to 2.4 mg/week)

MASH — With Concurrent T2DM

All of:

  • Diagnosis of MASH (formerly NASH)
  • Request is for Wegovy injection (not tablets)
  • Prescribed by or in consultation with a hepatologist or gastroenterologist
  • Age >= 18 years
  • MASH with stage F2 or F3 fibrosis confirmed by liver biopsy within last 3 years OR both a serum-based assessment (e.g., FIB-4, NFS, ELF) AND imaging-based assessment (e.g., VCTE, MRE, MRI-PDFF) within the last 6 months
  • Trial of >= 3 consecutive months each of ALL of: Ozempic or Rybelsus, Trulicity, and liraglutide (generic Victoza), unless clinically significant adverse effects or all are contraindicated (Note: IL HIM requests exempt as of 1/1/2026 per IL HB 5395)
  • Prescriber attestation of current standard of care management for concomitant related conditions (T2DM, dyslipidemia, hypertension)
  • Active enrollment in physician-directed weight loss program for at least 6 months with plan to continue
  • Wegovy not prescribed concurrently with Rezdiffra (resmetirom)
  • Wegovy not prescribed concurrently with other semaglutide-containing products or any other GLP-1 receptor agonist
  • Dose within approved escalation schedule (up to 2.4 mg/week)

Documentation to bring

  • Diagnosis of MASH (chart documentation)
  • Documentation that request is for Wegovy injection formulation
  • Documentation that prescriber is a hepatologist or gastroenterologist, or that prescription is in consultation with one
  • Age verification >= 18 years
  • MASH fibrosis staging (F2 or F3) confirmed by: liver biopsy within last 3 years OR both a serum-based test (FIB-4, NFS, or ELF) AND an imaging-based test (VCTE, MRE, or MRI-PDFF) within the last 6 months
  • Prescriber attestation of current standard of care management for T2DM, dyslipidemia, and hypertension
  • Documentation of active enrollment in physician-directed weight loss program for at least 6 months
  • Confirmation that Wegovy is not prescribed concurrently with Rezdiffra
  • For concurrent T2DM: documentation of >= 3-month trial each of Ozempic/Rybelsus, Trulicity, and liraglutide (generic Victoza) (unless adverse effects or all contraindicated), except IL HIM as of 1/1/2026

Quantity limits

  • 0.25mg, 0.5mg, 1mg
  • 1.7mg, 2.4mg

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • To renew, the plan looks for After at least 12 months of therapy, member must show positive response evidenced by at least one of: (1) improvement in fibrosis >= 1 stage from baseline with no worsening of MASH (no worsening of hepatocellular ballooning, lobular inflammation, or steatosis); (2) resolution of MASH with no worsening of fibrosis; or (3) no increase in fibrosis stage and no worsening of MASH from baseline. Maintenance dose >= 1.7 mg/week required. Standard of care for concomitant conditions re-verified. Prior GLP-1 step therapy NOT re-checked at continuation and staying on a maintenance dose of at least 1.7 mg.

Not covered when

  • Cirrhotic MASH (noncirrhotic only per FDA indication)
  • Concomitant use with Rezdiffra (resmetirom)
  • Concomitant use with other semaglutide-containing products
  • Concomitant use with any other GLP-1 receptor agonist
  • Wegovy tablets are not approved for MASH indication (injection only)
  • Personal or family history of medullary thyroid carcinoma (MTC) or MEN 2 (contraindication)
  • Known hypersensitivity to semaglutide or excipients
  • Intolerance due to common GI adverse effects of GLP-1 class is NOT acceptable justification for bypassing step therapy

Exceptions

  • Illinois: Step therapy requirements for members with concurrent T2DM do not apply for Illinois HIM requests as of 1/1/2026 per IL HB 5395

Policy note: MASH is defined as >= 5% hepatic steatosis with inflammation and hepatocyte injury (ballooning), with or without fibrosis. Fibrosis confirmation methods include combined scores: FAST score (FibroScan + AST), MAST score (MRI-PDFF + MRE + AST), MEFIB score (FIB-4 + MRE). Wegovy injection only — tablets are NOT approved for MASH. Continued FDA approval for MASH indication may be contingent on confirmatory trial verification. Biopsy lookback was revised from 6 months to 3 years per AASLD guidance in the 09.09.25 revision.

Policy effective June 1, 2024 · verified June 2, 2026 · source: CP.PMN.295.pdf

Why Wegovy requests get denied by Centene

Based on what this policy asks for. Fix these before the first submission.

  1. Your plan's benefit excludes weight loss medications. A prior authorization cannot override a benefit exclusion — ask about a formulary exception or a different covered pathway.
  2. Wrong brand for the diagnosis. Wegovy and Ozempic are the same molecule with different approved uses; a request for Wegovy under a diagnosis that matches Ozempic is routinely denied.
  3. BMI not documented in the chart notes (or documented without a baseline weight and date).
  4. No documented diet and exercise program.
  5. Required prior medication trials not documented.
  6. Prescriber isn't the specialist the plan requires.
  7. Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

If weight loss isn't covered on your plan

Centene has separate Wegovy policies that don't depend on the weight loss benefit:

Wegovy is also sold directly by Novo Nordisk without insurance through NovoCare.

Frequently asked questions

Does Centene cover Wegovy?
Centene does not cover it for weight loss on ACA Marketplace.
How long does a Wegovy approval last with Centene?
Initial approvals last 6 months, and renewals are granted in 12-month periods.
What does Centene require to renew Wegovy?
At least 5% weight loss from the starting weight, First renewal: must have lost >= 5% of baseline body weight. Second and subsequent renewals: must have lost weight and/or maintained weight loss. Maintenance dose >= 1.7 mg/week (injection) or 25 mg/day (tablet) required. GDMT requirement and lifestyle program enrollment re-verified at continuation. Prior GLP-1 step therapy NOT re-checked at continuation, and staying on a maintenance dose of at least 1.7 mg.
What if my plan excludes weight loss medications?
Centene has separate Wegovy policies for heart disease risk reduction and liver disease (mash), which are covered on some plan types and don't depend on the weight-loss benefit. Wegovy is also available for cash through NovoCare.
How current is this information?
This page reflects Centene's written policy as of June 1, 2024, last verified against the source document on June 2, 2026.

Other medications under Centene

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes Centene's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.