How long does a Wegovy approval last with Fallon Health Plan?

Weight Loss — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months. Heart Disease Risk Reduction — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.

What does Fallon Health Plan require to renew Wegovy?

Weight Loss — Applies to Medicaid plans. 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. Heart Disease Risk Reduction — Applies to Medicaid plans. 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.

How current is this information?

The oldest review date among the policies on this page is May 25, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Fallon Health Plan

Does Fallon Health Plan cover Wegovy?

Yes. Fallon Health Plan covers Wegovy for weight loss with prior authorization if your BMI is 35 or higher, or 30 or higher with a related condition. Other policy requirements and your plan's benefits also apply.

Policy document

Fallon Health Plan Medicaid prior authorization policy

Fallon Health Plan · PA policy · Medicaid

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Medicaid: Covered with requirements. See the qualification pathways below.

Earliest policy review May 25, 2026. How we verify · Check your exact plan

Full requirements: Wegovy for Weight Loss (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Adult/Pediatric (age ≥12) obesity – no comorbidities

All of:

BMI ≥ 35 kg/m² prior to initiation of pharmacotherapy

Adult/Pediatric (age ≥12) obesity – with qualifying comorbidity (BMI ≥ 30)

All of:

BMI ≥ 30 kg/m² prior to initiation of pharmacotherapy

Plus any one of:

Heart failure with preserved ejection fraction
Uncontrolled hypertension
Chronic kidney disease stage 3a or above
Moderate or severe obstructive sleep apnea

Adult/Pediatric (age ≥12) obesity – with qualifying comorbidity (BMI threshold not clearly specified in document)

All of:

BMI ≥ [threshold not clearly printed in source document] kg/m² prior to initiation of pharmacotherapy

Plus any one of:

Prediabetes (A1C ≥ 5.7% and < 6.5%) with documentation that member is NOT a candidate for antidiabetic GLP-1
History of myocardial infarction
History of stroke
Symptomatic peripheral artery disease
Type 2 diabetes mellitus
MASH with moderate to advanced liver fibrosis (F2 to F3)

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
Renewal: 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.

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: Fallon Health Plan Medicaid prior authorization policy · View policy document (PDF)

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Full requirements: Wegovy for Heart Disease Risk Reduction (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

CV risk reduction in adults with established CVD and obesity

All of:

Established cardiovascular disease (history of MI, history of stroke, or symptomatic PAD)
Obesity or overweight (BMI criteria same as weight loss indication)

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
Renewal: 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.

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: Fallon Health Plan Medicaid prior authorization policy · View policy document (PDF)

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Full requirements: Wegovy for Liver Disease (MASH) (1 plan type)

Applies to Medicaid plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

MASH with moderate to advanced liver fibrosis

All of:

Diagnosis of NASH or MASH
Moderate to advanced liver fibrosis (F2 to F3)

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: Fallon Health Plan Medicaid prior authorization policy · View policy document (PDF)

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Questions people ask

Does Fallon Health Plan cover Wegovy?: Yes. Fallon Health Plan covers Wegovy for weight loss with prior authorization if your BMI is 35 or higher, or 30 or higher with a related condition. Other policy requirements and your plan's benefits also apply.
How long does a Wegovy approval last with Fallon Health Plan?: Weight Loss — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months. Heart Disease Risk Reduction — Applies to Medicaid plans. Initial approval: 6 months. Renewal: every 6 months.
What does Fallon Health Plan require to renew Wegovy?: Weight Loss — Applies to Medicaid plans. 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. Heart Disease Risk Reduction — Applies to Medicaid plans. 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.
How current is this information?: The oldest review date among the policies on this page is May 25, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Fallon Health Plan: Ozempic

Wegovy under other plans: BCBS Massachusetts, Massachusetts Medicaid, Alabama Medicaid, California Medicaid, Clover Health, Colorado Medicaid, Connecticut Medicaid, Delaware Medicaid

All insurance plans · All medications

Summary of Fallon Health Plan's written policy, not a guarantee of coverage. Plans vary by employer and benefit design.