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Fallon Health Plan

Does Fallon Health Plan cover Wegovy for Weight Loss?

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

    View PDF Download
  • 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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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.
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.
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.