Applies to Federal Employee Program plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Wegovy injection — Adult (18+) weight loss initial approval
All of:
- Age 18 years or older
- Diagnosis of chronic weight management
- Participated in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- NO dual therapy with other GLP-1 receptor agonists
- NO dual therapy with another PA medication for weight loss
Plus any one of:
- BMI ≥ 30 kg/m2
- BMI ≥ 27 kg/m2 AND established cardiovascular disease (e.g., congenital heart disease, cerebrovascular disease, PAD, coronary heart disease, ACS, MI, unstable angina, coronary or other arterial revascularization, or prior PCI/CABG)
- BMI ≥ 27 kg/m2 AND at least one weight-related comorbid condition (e.g., T2DM, dyslipidemia, or hypertension)
Wegovy injection — Pediatric (age 12-17) weight loss initial approval
All of:
- Age 12 to 17 years
- Diagnosis of chronic weight management
- BMI ≥ 95th percentile for age
- Participated in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- NO dual therapy with other GLP-1 receptor agonists
- NO dual therapy with another PA medication for weight loss
Wegovy tablets — Adult (18+) weight loss initial approval
All of:
- Age 18 years or older
- Diagnosis of chronic weight management
- Participated in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- NO dual therapy with other GLP-1 receptor agonists
- NO dual therapy with another PA medication for weight loss
Plus any one of:
- BMI ≥ 30 kg/m2
- BMI ≥ 27 kg/m2 AND established cardiovascular disease (e.g., congenital heart disease, cerebrovascular disease, PAD, coronary heart disease, ACS, MI, unstable angina, coronary or other arterial revascularization, or prior PCI/CABG)
- BMI ≥ 27 kg/m2 AND at least one weight-related comorbid condition (e.g., T2DM, dyslipidemia, or hypertension)
Documentation to bring
- Documentation of BMI ≥ 30 kg/m2, OR BMI ≥ 27 kg/m2 with qualifying comorbidity or established CVD (adults 18+)
- Documentation of BMI ≥ 95th percentile for age (ages 12-17)
- Documentation of participation in a comprehensive weight management program (e.g., Teladoc or another weight loss program)
- Attestation of no dual therapy with another GLP-1 receptor agonist
- Attestation of no dual therapy with another PA-required weight loss medication
Quantity limits
- 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg — 12 single-dose pens per 84 days (84-day)
- 7.2mg — 12 single-dose pens per 84 days (84-day)
- All (tablets) — 90 tablets per 90 days (84-day)
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- Renewal: Adults (18+): patient has lost at least 5% of baseline body weight OR continued to maintain their initial 5% weight loss. Ages 12-17: patient has maintained clinically significant weight loss. Comprehensive weight management program participation also required at renewal. BMI/comorbidity thresholds are NOT re-verified at continuation.
Not covered when
- Dual therapy with any other GLP-1 receptor agonist
- Dual therapy with another PA-required weight loss medication
Policy note: Wegovy injection approved for ages 12+; Wegovy tablets approved for ages 18+ only. Quantity limit for Wegovy injection applies across all strengths (0.25mg–2.4mg and 7.2mg): 12 single-dose pens per 84 days. Wegovy tablets: 90 tablets per 90 days. Initial approval duration is 6 months; renewal duration is 12 months. The policy applies to both the injection and oral tablet formulations. CVD qualifying events listed for the 27 kg/m2 BMI pathway include: congenital heart disease, cerebrovascular disease, peripheral artery disease, coronary heart disease, ACS, MI, unstable angina, coronary or other arterial revascularization, or prior PCI/coronary bypass surgery. Policy approved by FEP Pharmacy and Medical Policy Committee.
Policy effective July 1, 2026 · verified July 27, 2026 · source: Fep Criteria Wegovy · View policy document (PDF)