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 (HTN, T2DM, dyslipidemia, OSA, CVD, knee_osteoarthritis, asthma, COPD, MASLD/NAFLD, PCOS, and CAD)
- BMI at or above the 95th percentile for age and sex
- 3 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Initial Approval - Adult Weight Loss (BMI >= 30)
All of:
- Patient is >= 18 years of age
- Baseline BMI >= 30 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Initial Approval - Adult Weight Loss (BMI >= 27 with comorbidity)
All of:
- Patient is >= 18 years of age
- Baseline BMI >= 27 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Plus any one of:
- At baseline or currently: hypertension
- At baseline or currently: type 2 diabetes
- At baseline or currently: dyslipidemia
- At baseline or currently: obstructive sleep apnea
- At baseline or currently: cardiovascular disease
- At baseline or currently: knee osteoarthritis
- At baseline or currently: asthma
- At baseline or currently: COPD
- At baseline or currently: MASLD/NAFLD
- At baseline or currently: polycystic ovarian syndrome
- At baseline or currently: coronary artery disease
Initial Approval - Pediatric Weight Loss (age 12-17)
All of:
- Patient is >= 12 years of age and < 18 years of age
- Baseline BMI >= 95th percentile for age and sex (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
Continuation - Adult Weight Loss (BMI >= 30)
All of:
- Patient is >= 18 years of age
- Baseline BMI >= 30 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has lost >= 5% of baseline body weight
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Patient has completed >= 8 months of initial therapy
Continuation - Adult Weight Loss (BMI >= 27 with comorbidity)
All of:
- Patient is >= 18 years of age
- Baseline BMI >= 27 kg/m2 (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has lost >= 5% of baseline body weight
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Patient has completed >= 8 months of initial therapy
Plus any one of:
- At baseline or currently: hypertension
- At baseline or currently: type 2 diabetes
- At baseline or currently: dyslipidemia
- At baseline or currently: obstructive sleep apnea
- At baseline or currently: cardiovascular disease
- At baseline or currently: knee osteoarthritis
- At baseline or currently: asthma
- At baseline or currently: COPD
- At baseline or currently: MASLD/NAFLD
- At baseline or currently: polycystic ovarian syndrome
- At baseline or currently: coronary artery disease
Continuation - Pediatric Weight Loss (age 12-17)
All of:
- Patient is >= 12 years of age and < 18 years of age
- Baseline BMI >= 95th percentile for age and sex (prior to any GLP-1 or GLP-1/GIP agonist)
- Patient has had a reduction in BMI of >= 1% from baseline
- Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
- Patient has completed >= 7 months of initial therapy with Wegovy injection, Wegovy HD injection, and/or Wegovy tablet
Documentation to bring
- Baseline BMI documentation (>= 30 kg/m2, or >= 27 kg/m2 with qualifying comorbidity)
- Documentation of at least 3-month trial of behavioral modification and dietary restriction (initial therapy)
- Documentation of qualifying weight-related comorbidity if BMI 27-29.9 kg/m2
- Documentation of >= 5% baseline body weight loss (continuation, adult)
- Documentation of >= 1% BMI reduction from baseline (continuation, pediatric)
Approval and renewal
- Initial approval: 8 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, at least 1% reduction in BMI, and Adults: must have lost >= 5% of baseline body weight. Pediatric (age 12-17): must have had >= 1% reduction in BMI from baseline. Baseline BMI/weight re-verified at continuation, but 3-month lifestyle program requirement is not re-checked. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Concomitant use with other GLP-1 agonists or GLP-1/GIP agonists is not covered
- Any use not meeting FDA-approved indications or criteria above is not medically necessary
Policy note: Wegovy injection (including Wegovy HD injection) and Wegovy tablet are both covered under the same weight loss criteria. Wegovy HD injection is intended for patients who have tolerated Wegovy 2.4 mg SC for >= 4 weeks and require additional weight reduction. Pediatric approval applies to Wegovy injection only (not Wegovy tablet, which is not FDA-approved for pediatric use). Initial approval is for 8 months; continuation is for 1 year. For pediatric continuation, patient must have completed >= 7 months of initial therapy (note: policy states 7 months in the pediatric continuation note, while adult states 8 months).
Policy effective April 15, 2026 · verified June 2, 2026 · source: cnf_684_coveragepositioncriteria_weight_loss_glp1_agonists_pa.pdf