Does Fallon Health Plan cover Wegovy?

What you need to qualify

• Age 12 and older
• BMI of 35 or higher
• BMI of 30 or higher with a weight-related condition (heart failure with preserved ejection fraction, uncontrolled hypertension, CKD stage 3a or above, moderate or severe OSA, prediabetes (A1c >= 5.7% and < 6.5%) with documentation member is NOT a candidate for antidiabetic GLP-1, history of MI, history of stroke, symptomatic PAD, T2DM, and MASH with moderate to advanced liver fibrosis (F2 to F3))

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline BMI documentation
• Documentation of qualifying comorbidity if BMI < 35 kg/m²
• For prediabetes comorbidity: documentation of A1c >= 5.7% and < 6.5% AND documentation of why member is NOT a candidate for antidiabetic GLP-1
• For continuation: documentation of >= 5% weight loss from baseline OR documentation of established CVD OR documentation of improvement in OSA symptoms with AHI >= 15 and provider attestation OR documentation of improvement in secondary measures and provider attestation

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and At least one of: (1) weight loss >= 5% from baseline body weight; (2) established CVD (history of MI, stroke, symptomatic PAD) and using GLP-1 for cardiovascular risk reduction; (3) documentation of improvement in OSA symptoms with attestation that improvement is related to anti-obesity therapy despite lack of weight reduction AND medical records documenting baseline or current AHI >= 15; (4) documentation of improvement in secondary measures (e.g., blood pressure, blood glucose) with attestation that improvements are related to anti-obesity therapy despite lack of weight reduction. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Policy note: The document appears to have a formatting gap: the BMI threshold for the third comorbidity tier is listed as 'BMI >= kg/m²' with the numeric value missing. The step-through phentermine requirement has been explicitly removed as of February 17, 2026. Criteria are shared with Zepbound for adult members for weight loss, CV risk reduction, and OSA indications. For pediatric members (age 12 to <18), a step through Wegovy was added for Saxenda, and pediatric criteria were added for Wegovy itself (age 12 to <18).

source: Pa policy

What you need to qualify

• Age 18 and older
• BMI of 35 or higher
• BMI of 30 or higher with a weight-related condition (established cardiovascular disease)
• Established cardiovascular disease (MI, stroke, and symptomatic PAD)

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Documentation of established cardiovascular disease (history of MI, history of stroke, or symptomatic PAD)
• Baseline BMI documentation
• For continuation: documentation of established CVD and using GLP-1 for cardiovascular risk reduction, OR >= 5% weight loss, OR improvement in secondary measures with provider attestation

Approval and renewal

• Initial approval: 6 months
• Renewal: every 6 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and At least one of: (1) weight loss >= 5% from baseline body weight; (2) established CVD (history of MI, stroke, symptomatic PAD) and using GLP-1 for cardiovascular risk reduction; (3) documentation of improvement in OSA symptoms with attestation related to anti-obesity therapy despite lack of weight reduction AND AHI >= 15; (4) documentation of improvement in secondary measures with provider attestation related to anti-obesity therapy despite lack of weight reduction. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Policy note: CV risk reduction indication shares the same criteria framework as weight_loss indication for Wegovy and Zepbound per the February 17, 2026 update. The continuation criteria explicitly allow continuation if member has established CVD and is using GLP-1 for cardiovascular risk reduction even without weight loss. Adults only (not pediatric) based on context.

source: Pa policy

What you need to qualify

• Confirmed MASH diagnosis, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Diagnosis of NASH or MASH
• Documentation of fibrosis stage F2 or F3

Policy note: MASH indication for Wegovy was added January 5, 2026. The document describes coverage for 'moderate to advanced liver fibrosis' (F2 to F3). No additional details on confirmation methods, lookback periods, specialist requirements, alcohol limits, or approval duration were specified in this guideline update summary. Full criteria detail may exist in a separate policy document.

source: Pa policy