Elevance Health

Does Elevance Health cover Wegovy?

Quick answer · Weight Loss

Elevance Health covers it only when the plan's benefit includes it on Employer / Commercial Insurance and ACA Marketplace.

  • Employer / Commercial Insurance: Depends on your plan's benefit. Coverage applies only when member's benefit covers weight loss drugs and requires prior authorization. Employer or plan must have weight loss drug benefit.
  • ACA Marketplace: Depends on your plan's benefit. Coverage applies only when member's benefit covers weight loss drugs and requires prior authorization. Employer or plan must have weight loss drug benefit.

Last verified June 2, 2026. Policy effective April 3, 2026. Source: Download. How we verify this data →

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Wegovy for Weight Loss

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

Employer / Commercial Insurance

Depends on your plan's benefit

Coverage applies only when member's benefit covers weight loss drugs and requires prior authorization. Employer or plan must have weight loss drug benefit.

What 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, and CVD)
  • 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 initial approval - BMI >= 30

All of:

  • Age >= 18 years
  • BMI >= 30 kg/m2 documented within 90 days of request
  • Trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction
  • Currently maintained on healthcare provider supervised lifestyle program
  • Not receiving two or more medications for weight loss simultaneously
  • Healthcare provider consultation regarding risks, benefits, and realistic expectations

Adult initial approval - BMI >= 27 with weight-related comorbidity

All of:

  • Age >= 18 years
  • BMI >= 27 kg/m2 documented within 90 days of request
  • Trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction
  • Currently maintained on healthcare provider supervised lifestyle program
  • Not receiving two or more medications for weight loss simultaneously
  • Healthcare provider consultation regarding risks, benefits, and realistic expectations

Plus any one of:

  • Hypertension (treated or SBP >= 130 mmHg or DBP >= 80 mmHg)
  • Type II Diabetes Mellitus
  • Dyslipidemia (treated or LDL >= 160 mg/dL or triglycerides >= 150 mg/dL or HDL <40 mg/dL [men] or <50 mg/dL [women])
  • Obstructive sleep apnea (as a result of BMI >= 27)
  • Cardiovascular disease (ischemic CVD or NYHA Class I-III heart failure)

Adolescent initial approval (ages 12-17)

All of:

  • Age 12 to 17 years
  • BMI >= 95th percentile for age and sex documented within 90 days of request
  • Individual and caregiver utilized healthy nutrition and behavior counseling for >= 6 months with inadequate weight reduction
  • Currently maintained on healthy nutrition and behavior counseling
  • Not receiving two or more medications for weight loss simultaneously
  • Healthcare provider consultation regarding risks, benefits, and realistic expectations

Documentation to bring

  • Documentation of BMI >= 30 kg/m2 (adults) or BMI >= 95th percentile for age and sex (adolescents) within 90 days of request
  • For adults with BMI 27-29: documentation of at least one weight-related comorbidity (HTN, T2DM, dyslipidemia, OSA from BMI >= 27, or CVD)
  • Documentation of prior trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months (adults: including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction; adolescents: healthy nutrition and behavior counseling for >= 6 months with inadequate weight reduction)
  • Documentation of current enrollment and maintenance in healthcare provider supervised lifestyle program
  • Documentation that individual is NOT receiving two or more weight loss medications simultaneously
  • Documentation of healthcare provider consultation regarding risks, benefits, realistic expectations, and need for long-term follow-up and behavior modification adherence
  • For continuation (adults): Documentation of achieved/maintained >= 5% weight loss within 90 days of continuation request
  • For continuation (adolescents): Documentation of achieved/maintained >4% reduction from baseline BMI within 90 days of continuation request
  • For continuation: Documentation of continued engagement in comprehensive lifestyle program (adults) or healthy nutrition and behavior counseling (adolescents)

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg, 7.2mg — Subject to quantity limit (specific limit not detailed in document)

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 6 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight, at least 4% reduction in BMI, and Adults: Documentation of achieved/maintained initial 5% weight loss (required within 90 days of each continuation request). BMI eligibility criteria are re-verified based on BMI at initiation of therapy (not current BMI). Continued engagement in comprehensive lifestyle program required. Adolescents: Documentation of achieved/maintained >4% reduction from baseline BMI (required within 90 days of each continuation request). Continued healthy nutrition and behavior counseling required. Note: The 5% continuation threshold applies to adults; the 4% BMI reduction threshold applies to adolescents. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • BMI < 18.5 kg/m2
  • Use for treatment of type 2 diabetes mellitus
  • Personal or family history of medullary thyroid carcinoma (MTC)
  • Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
  • History of pancreatitis
  • Concurrent use of another semaglutide agent or any other GLP-1 agonist
  • History of suicide attempts or active suicidal ideation
  • Receiving two or more medications for weight loss simultaneously

Policy note: Initial approval duration is 28 weeks (approximately 7 months) for both adults and adolescents. Continuation approvals are 6 months. Adults use injection or tablets (0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg, 7.2 mg); adolescents use injection only (0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg). Coverage is conditioned on member's benefit covering weight loss drugs. Adult continuation re-verifies BMI eligibility using BMI at initiation of therapy (not current). Adolescent continuation requires >4% reduction from baseline BMI. Weight loss for treatment of T2DM is explicitly excluded (use for T2DM treatment is a denial reason). T1DM is not explicitly listed as a weight loss exclusion for adolescents, but is listed for adults in the adult exclusion section. Document references both a 7.2 mg strength for adults (not listed for adolescents). Dyslipidemia qualifying comorbidity is specifically defined with lab thresholds. OSA as comorbidity requires it to be 'as a result of having a BMI of 27 or greater.' Exercise exception allowed for clinical limitations including cardiovascular conditions, physical limitations, or fall risk.

Policy effective April 3, 2026 · verified June 2, 2026 · source: Download

ACA Marketplace

Depends on your plan's benefit

Coverage applies only when member's benefit covers weight loss drugs and requires prior authorization. Employer or plan must have weight loss drug benefit.

What 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, and CVD)
  • 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 initial approval - BMI >= 30

All of:

  • Age >= 18 years
  • BMI >= 30 kg/m2 documented within 90 days of request
  • Trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction
  • Currently maintained on healthcare provider supervised lifestyle program
  • Not receiving two or more medications for weight loss simultaneously
  • Healthcare provider consultation regarding risks, benefits, and realistic expectations

Adult initial approval - BMI >= 27 with weight-related comorbidity

All of:

  • Age >= 18 years
  • BMI >= 27 kg/m2 documented within 90 days of request
  • Trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction
  • Currently maintained on healthcare provider supervised lifestyle program
  • Not receiving two or more medications for weight loss simultaneously
  • Healthcare provider consultation regarding risks, benefits, and realistic expectations

Plus any one of:

  • Hypertension (treated or SBP >= 130 mmHg or DBP >= 80 mmHg)
  • Type II Diabetes Mellitus
  • Dyslipidemia (treated or LDL >= 160 mg/dL or triglycerides >= 150 mg/dL or HDL <40 mg/dL [men] or <50 mg/dL [women])
  • Obstructive sleep apnea (as a result of BMI >= 27)
  • Cardiovascular disease (ischemic CVD or NYHA Class I-III heart failure)

Adolescent initial approval (ages 12-17)

All of:

  • Age 12 to 17 years
  • BMI >= 95th percentile for age and sex documented within 90 days of request
  • Individual and caregiver utilized healthy nutrition and behavior counseling for >= 6 months with inadequate weight reduction
  • Currently maintained on healthy nutrition and behavior counseling
  • Not receiving two or more medications for weight loss simultaneously
  • Healthcare provider consultation regarding risks, benefits, and realistic expectations

Documentation to bring

  • Documentation of BMI >= 30 kg/m2 (adults) or BMI >= 95th percentile for age and sex (adolescents) within 90 days of request
  • For adults with BMI 27-29: documentation of at least one weight-related comorbidity (HTN, T2DM, dyslipidemia, OSA from BMI >= 27, or CVD)
  • Documentation of prior trial and failure of healthcare provider supervised comprehensive lifestyle program for >= 6 months (adults: including calorie deficit ~30%, >= 150 min/week exercise, and inability to achieve >= 5% weight reduction; adolescents: healthy nutrition and behavior counseling for >= 6 months with inadequate weight reduction)
  • Documentation of current enrollment and maintenance in healthcare provider supervised lifestyle program
  • Documentation that individual is NOT receiving two or more weight loss medications simultaneously
  • Documentation of healthcare provider consultation regarding risks, benefits, realistic expectations, and need for long-term follow-up and behavior modification adherence
  • For continuation (adults): Documentation of achieved/maintained >= 5% weight loss within 90 days of continuation request
  • For continuation (adolescents): Documentation of achieved/maintained >4% reduction from baseline BMI within 90 days of continuation request
  • For continuation: Documentation of continued engagement in comprehensive lifestyle program (adults) or healthy nutrition and behavior counseling (adolescents)

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg, 7.2mg — Subject to quantity limit (specific limit not detailed in document)

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 6 months
  • To renew, the plan looks for at least 5% weight loss from the starting weight, at least 4% reduction in BMI, and Adults: Documentation of achieved/maintained initial 5% weight loss (required within 90 days of each continuation request). BMI eligibility criteria are re-verified based on BMI at initiation of therapy (not current BMI). Continued engagement in comprehensive lifestyle program required. Adolescents: Documentation of achieved/maintained >4% reduction from baseline BMI (required within 90 days of each continuation request). Continued healthy nutrition and behavior counseling required. Note: The 5% continuation threshold applies to adults; the 4% BMI reduction threshold applies to adolescents. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • BMI < 18.5 kg/m2
  • Use for treatment of type 2 diabetes mellitus
  • Personal or family history of medullary thyroid carcinoma (MTC)
  • Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
  • History of pancreatitis
  • Concurrent use of another semaglutide agent or any other GLP-1 agonist
  • History of suicide attempts or active suicidal ideation
  • Receiving two or more medications for weight loss simultaneously

Policy note: Initial approval duration is 28 weeks (approximately 7 months) for both adults and adolescents. Continuation approvals are 6 months. Adults use injection or tablets (0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg, 7.2 mg); adolescents use injection only (0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg). Coverage is conditioned on member's benefit covering weight loss drugs. Adult continuation re-verifies BMI eligibility using BMI at initiation of therapy (not current). Adolescent continuation requires >4% reduction from baseline BMI. Weight loss for treatment of T2DM is explicitly excluded (use for T2DM treatment is a denial reason). T1DM is not explicitly listed as a weight loss exclusion for adolescents, but is listed for adults in the adult exclusion section. Document references both a 7.2 mg strength for adults (not listed for adolescents). Dyslipidemia qualifying comorbidity is specifically defined with lab thresholds. OSA as comorbidity requires it to be 'as a result of having a BMI of 27 or greater.' Exercise exception allowed for clinical limitations including cardiovascular conditions, physical limitations, or fall risk.

Policy effective April 3, 2026 · verified June 2, 2026 · source: Download

Wegovy for Heart Disease Risk Reduction

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

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • A1C no higher than 6.5%
  • Established cardiovascular disease (MI, stroke, and PAD)
  • On guideline-directed medical therapy (antiplatelet_therapy, anticoagulant_therapy, high_intensity_statin, ACE_inhibitor, ARB, calcium_channel_blocker, thiazide_diuretic, and beta_blocker (required for history of MI))
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

CV risk reduction in adults without diabetes

All of:

  • Established cardiovascular disease (prior MI, prior stroke, or symptomatic PAD)
  • HbA1c < 6.5% (48 mmol/mol) — excludes Type 2 diabetes
  • BMI >= 27 kg/m2 documented within 90 days of request
  • Established on GDMT including antiplatelet/anticoagulant therapy, high-intensity statin, and blood pressure lowering therapy (unless not tolerated or not clinically warranted); beta blocker required for history of MI
  • Wegovy used as add-on to GDMT
  • Wegovy used in combination with healthy lifestyle counseling
  • Wegovy used in combination with reduced calorie diet and increased physical activity

Plus any one of:

  • Previous myocardial infarction
  • Previous stroke (ischemic or hemorrhagic)
  • Symptomatic peripheral arterial disease (intermittent claudication with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)

Documentation to bring

  • Documentation of qualifying established CVD event: prior MI, prior stroke, or symptomatic PAD (with ABI <0.85, revascularization, or amputation)
  • HbA1c lab result < 6.5% (48 mmol/mol)
  • BMI documentation >= 27 kg/m2 within 90 days of request
  • Documentation of current GDMT use (antiplatelet/anticoagulant, high-intensity statin, blood pressure lowering therapy) or clinical reason not appropriate
  • Documentation of beta blocker use for individuals with history of MI, or clinical reason not appropriate
  • Confirmation that Wegovy will be used as add-on to GDMT
  • Confirmation that Wegovy will be used with healthy lifestyle counseling and reduced calorie diet and increased physical activity

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — Subject to quantity limit (specific limit not detailed in document)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Continuation criteria not explicitly detailed in the document beyond initial approval duration of 1 year. No separate continuation criteria listed for CV risk reduction indication.

Not covered when

  • BMI < 18.5 kg/m2
  • Type 2 diabetes (HbA1c >= 6.5%)
  • Personal or family history of Medullary Thyroid Carcinoma (MTC)
  • Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
  • Concurrent use of another semaglutide agent or any other GLP-1 agonist
  • History of suicide attempts or active suicidal ideation
  • Type 1 diabetes

Policy note: The CV risk reduction indication explicitly excludes both Type 1 and Type 2 diabetes (HbA1c must be < 6.5%). Symptomatic PAD is defined as intermittent claudication with ankle-brachial index <0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease. GDMT requirement has exceptions for intolerance or lack of clinical warrant. Beta blocker is only required for individuals with history of MI. BMI documentation must be within 90 days of request. Approval duration is 1 year.

Policy effective April 3, 2026 · verified June 2, 2026 · source: Download

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • A1C no higher than 6.5%
  • Established cardiovascular disease (MI, stroke, and PAD)
  • On guideline-directed medical therapy (antiplatelet_therapy, anticoagulant_therapy, high_intensity_statin, ACE_inhibitor, ARB, calcium_channel_blocker, thiazide_diuretic, and beta_blocker (required for history of MI))
  • Lab results confirming eligibility
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

CV risk reduction in adults without diabetes

All of:

  • Established cardiovascular disease (prior MI, prior stroke, or symptomatic PAD)
  • HbA1c < 6.5% (48 mmol/mol) — excludes Type 2 diabetes
  • BMI >= 27 kg/m2 documented within 90 days of request
  • Established on GDMT including antiplatelet/anticoagulant therapy, high-intensity statin, and blood pressure lowering therapy (unless not tolerated or not clinically warranted); beta blocker required for history of MI
  • Wegovy used as add-on to GDMT
  • Wegovy used in combination with healthy lifestyle counseling
  • Wegovy used in combination with reduced calorie diet and increased physical activity

Plus any one of:

  • Previous myocardial infarction
  • Previous stroke (ischemic or hemorrhagic)
  • Symptomatic peripheral arterial disease (intermittent claudication with ABI <0.85, peripheral arterial revascularization, or amputation due to atherosclerotic disease)

Documentation to bring

  • Documentation of qualifying established CVD event: prior MI, prior stroke, or symptomatic PAD (with ABI <0.85, revascularization, or amputation)
  • HbA1c lab result < 6.5% (48 mmol/mol)
  • BMI documentation >= 27 kg/m2 within 90 days of request
  • Documentation of current GDMT use (antiplatelet/anticoagulant, high-intensity statin, blood pressure lowering therapy) or clinical reason not appropriate
  • Documentation of beta blocker use for individuals with history of MI, or clinical reason not appropriate
  • Confirmation that Wegovy will be used as add-on to GDMT
  • Confirmation that Wegovy will be used with healthy lifestyle counseling and reduced calorie diet and increased physical activity

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — Subject to quantity limit (specific limit not detailed in document)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Continuation criteria not explicitly detailed in the document beyond initial approval duration of 1 year. No separate continuation criteria listed for CV risk reduction indication.

Not covered when

  • BMI < 18.5 kg/m2
  • Type 2 diabetes (HbA1c >= 6.5%)
  • Personal or family history of Medullary Thyroid Carcinoma (MTC)
  • Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
  • Concurrent use of another semaglutide agent or any other GLP-1 agonist
  • History of suicide attempts or active suicidal ideation
  • Type 1 diabetes

Policy note: The CV risk reduction indication explicitly excludes both Type 1 and Type 2 diabetes (HbA1c must be < 6.5%). Symptomatic PAD is defined as intermittent claudication with ankle-brachial index <0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease. GDMT requirement has exceptions for intolerance or lack of clinical warrant. Beta blocker is only required for individuals with history of MI. BMI documentation must be within 90 days of request. Approval duration is 1 year.

Policy effective April 3, 2026 · verified June 2, 2026 · source: Download

Wegovy for Liver Disease (MASH)

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

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • 6 months of a documented diet and exercise program
  • Confirmed MASH diagnosis by FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

MASH diagnosis verification via imaging alone

All of:

  • Age >= 18 years
  • Diagnosis of noncirrhotic, nonalcoholic MASH
  • Steatosis confirmed by FibroScan VCTE or MRE within the past year
  • Moderate to advanced liver fibrosis consistent with stages F2 or F3
  • Prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program
  • Will continue to be maintained on healthcare provider supervised comprehensive lifestyle program

MASH diagnosis verification via liver biopsy with NAS score

All of:

  • Age >= 18 years
  • Diagnosis of noncirrhotic, nonalcoholic MASH
  • Liver biopsy within the past 3 years
  • NAS score >= 4
  • Score of at least 1 in two or more NAS components (steatosis, hepatocellular ballooning, lobular inflammation)
  • Moderate to advanced liver fibrosis consistent with stages F2 or F3
  • Prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program
  • Will continue to be maintained on healthcare provider supervised comprehensive lifestyle program

Documentation to bring

  • Documentation of age >= 18 years
  • Diagnosis of noncirrhotic MASH (formerly NASH)
  • Imaging or biopsy confirming diagnosis: FibroScan VCTE or MRE within the past year, OR liver biopsy within the past 3 years with NAS score >= 4 and score of at least 1 in two or more NAS components
  • Documentation of moderate to advanced liver fibrosis (F2 or F3)
  • Documentation of prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program (worsening or no improvement in NAS score, NAS components, or fibrosis stage)
  • Documentation that individual will continue to be maintained on healthcare provider supervised comprehensive lifestyle program

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — Subject to quantity limit (specific limit not detailed in document)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Improvement from baseline in NAFLD Activity Score (NAS) without worsening of fibrosis stage; OR improvement from baseline in fibrosis stage with no worsening of NAS; OR improvement in fibrosis stage based on FibroScan VCTE or MRE. Continued enrollment in healthcare provider supervised comprehensive lifestyle program required.

Not covered when

  • BMI < 18.5 kg/m2
  • Cirrhosis (stage 4 fibrosis)
  • Evidence of other forms of chronic liver disease
  • Personal or family history of Medullary Thyroid Carcinoma (MTC)
  • Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
  • History of pancreatitis
  • Severe gastroparesis
  • History of suicide attempts or active suicidal ideation
  • Concurrent use of other semaglutide-containing products or any other GLP-1 receptor agonist (including Ozempic, Rybelsus, Zepbound, Mounjaro, Saxenda, Victoza)
  • Type 1 diabetes

Policy note: Diagnosis must be noncirrhotic MASH. Imaging confirmation (FibroScan VCTE or MRE) lookback is 12 months; liver biopsy lookback is 36 months. Continuation requires improvement in NAS or fibrosis stage. Pregnancy exclusion not explicitly listed in document but is a standard GLP-1 exclusion; document does not state it explicitly so set to false.

Policy effective April 3, 2026 · verified June 2, 2026 · source: Download

ACA Marketplace

Covered with requirements

What you need to qualify

  • Age 18 and older
  • 6 months of a documented diet and exercise program
  • Confirmed MASH diagnosis by FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

MASH diagnosis verification via imaging alone

All of:

  • Age >= 18 years
  • Diagnosis of noncirrhotic, nonalcoholic MASH
  • Steatosis confirmed by FibroScan VCTE or MRE within the past year
  • Moderate to advanced liver fibrosis consistent with stages F2 or F3
  • Prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program
  • Will continue to be maintained on healthcare provider supervised comprehensive lifestyle program

MASH diagnosis verification via liver biopsy with NAS score

All of:

  • Age >= 18 years
  • Diagnosis of noncirrhotic, nonalcoholic MASH
  • Liver biopsy within the past 3 years
  • NAS score >= 4
  • Score of at least 1 in two or more NAS components (steatosis, hepatocellular ballooning, lobular inflammation)
  • Moderate to advanced liver fibrosis consistent with stages F2 or F3
  • Prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program
  • Will continue to be maintained on healthcare provider supervised comprehensive lifestyle program

Documentation to bring

  • Documentation of age >= 18 years
  • Diagnosis of noncirrhotic MASH (formerly NASH)
  • Imaging or biopsy confirming diagnosis: FibroScan VCTE or MRE within the past year, OR liver biopsy within the past 3 years with NAS score >= 4 and score of at least 1 in two or more NAS components
  • Documentation of moderate to advanced liver fibrosis (F2 or F3)
  • Documentation of prior trial and inadequate response to healthcare provider supervised comprehensive lifestyle program (worsening or no improvement in NAS score, NAS components, or fibrosis stage)
  • Documentation that individual will continue to be maintained on healthcare provider supervised comprehensive lifestyle program

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — Subject to quantity limit (specific limit not detailed in document)

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Improvement from baseline in NAFLD Activity Score (NAS) without worsening of fibrosis stage; OR improvement from baseline in fibrosis stage with no worsening of NAS; OR improvement in fibrosis stage based on FibroScan VCTE or MRE. Continued enrollment in healthcare provider supervised comprehensive lifestyle program required.

Not covered when

  • BMI < 18.5 kg/m2
  • Cirrhosis (stage 4 fibrosis)
  • Evidence of other forms of chronic liver disease
  • Personal or family history of Medullary Thyroid Carcinoma (MTC)
  • Diagnosis of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
  • History of pancreatitis
  • Severe gastroparesis
  • History of suicide attempts or active suicidal ideation
  • Concurrent use of other semaglutide-containing products or any other GLP-1 receptor agonist (including Ozempic, Rybelsus, Zepbound, Mounjaro, Saxenda, Victoza)
  • Type 1 diabetes

Policy note: Diagnosis must be noncirrhotic MASH. Imaging confirmation (FibroScan VCTE or MRE) lookback is 12 months; liver biopsy lookback is 36 months. Continuation requires improvement in NAS or fibrosis stage. Pregnancy exclusion not explicitly listed in document but is a standard GLP-1 exclusion; document does not state it explicitly so set to false.

Policy effective April 3, 2026 · verified June 2, 2026 · source: Download

Why Wegovy requests get denied by Elevance Health

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

  1. Your specific plan doesn't include the weight loss benefit. Coverage here is conditional on the benefit design (often an optional employer add-on), so confirm it before submitting.
  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. Qualifying weight-related condition not documented with its own diagnosis code.
  5. No documented diet and exercise program.
  6. 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

Elevance Health 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 Elevance Health cover Wegovy?
Elevance Health covers it only when the plan's benefit includes it on Employer / Commercial Insurance and ACA Marketplace.
What BMI do you need for Wegovy under Elevance Health?
For weight loss on Employer / Commercial Insurance plans, Elevance Health requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition. Other plan types may differ — see each plan type below.
How long does a Wegovy approval last with Elevance Health?
Initial approvals last 7 months, and renewals are granted in 6-month periods.
What does Elevance Health require to renew Wegovy?
At least 5% weight loss from the starting weight, at least 4% reduction in BMI, and Adults: Documentation of achieved/maintained initial 5% weight loss (required within 90 days of each continuation request). BMI eligibility criteria are re-verified based on BMI at initiation of therapy (not current BMI). Continued engagement in comprehensive lifestyle program required. Adolescents: Documentation of achieved/maintained >4% reduction from baseline BMI (required within 90 days of each continuation request). Continued healthy nutrition and behavior counseling required. Note: The 5% continuation threshold applies to adults; the 4% BMI reduction threshold applies to adolescents.
What if my plan excludes weight loss medications?
Elevance Health 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 Elevance Health's written policy as of April 3, 2026, last verified against the source document on June 2, 2026.

Other medications under Elevance Health

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes Elevance Health'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.