Applies to Employer plans.
Covered with requirementsQualification pathways
You can qualify through any one of these.
Adult weight management
All of:
- Patient is new to therapy, new to Prime, or attempting a repeat weight loss course
- Patient is an adult (18 years of age or over)
- Inadequate response to low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months prior to therapy
- Patient is currently on and will continue weight management regimen in combination with the requested agent
- Patient will NOT use requested agent in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications
- ONE of the Wegovy continuation criteria met: starting therapy, less than 52 weeks of therapy, or achieved and maintained ≥ 5% weight loss from baseline
Plus any one of:
- Pretreatment BMI ≥ 30 kg/m2
- Pretreatment BMI ≥ 25 kg/m2 if patient is of South Asian, Southeast Asian, or East Asian descent
- Pretreatment BMI ≥ 27 kg/m2 with at least one weight-related comorbidity/risk factor/complication (e.g., hypertension, T2DM, OSA, CVD, dyslipidemia)
Pediatric weight management (12-17 years)
All of:
- Patient is new to therapy, new to Prime, or attempting a repeat weight loss course
- Patient is pediatric (12 to 17 years of age)
- Inadequate response to low-calorie diet, increased physical activity, and behavioral modifications for a minimum of 6 months prior to therapy
- Patient is currently on and will continue weight management regimen in combination with the requested agent
- Patient will NOT use requested agent in combination with another weight loss agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications
- ONE of the Wegovy continuation criteria met: starting therapy, less than 52 weeks of therapy, or achieved and maintained ≥ 5% BMI reduction from baseline (pediatric)
Plus any one of:
- Pretreatment BMI ≥ 95th percentile for age and sex
- Pretreatment BMI ≥ 30 kg/m2
- Pretreatment BMI ≥ 85th percentile for age and sex AND at least one weight-related comorbidity/risk factor/complication (e.g., hypertension, dyslipidemia, T2DM, OSA)
Another FDA labeled indication (weight management pathway override)
All of:
- Patient has another FDA labeled indication for the requested agent and route of administration
- Patient will NOT use requested agent in combination with another weight loss agent
- Patient will NOT use requested agent in combination with another GLP-1 receptor agonist
- Patient does NOT have any FDA labeled contraindications
- Patient is currently on and will continue weight management regimen
Documentation to bring
- Baseline BMI documentation
- Documentation of at least 6 months of inadequate response to low-calorie diet, increased physical activity, and behavioral modifications (for initial approval)
- Documentation that patient is currently on weight management regimen (diet, physical activity, behavioral modifications)
- For Asian descent patients: documentation of ethnicity supporting lower BMI threshold
- For patients with comorbidities qualifying at BMI ≥ 27: documentation of qualifying comorbidity
- For pediatric patients: documentation of BMI percentile for age and sex
- Confirmation that patient will not combine with another weight loss agent or GLP-1 RA
- For continuation: documentation of weight loss ≥ 5% from baseline (adults) or BMI reduction ≥ 5% from baseline (pediatric), OR documentation of being within 52 weeks of therapy on maximum-tolerated dose
Quantity limits
- 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML — 8 pens per 180-day supply (84-day)
- 1.7 MG/0.75ML, 2.4 MG/0.75ML — 4 pens per 28-day supply
- 7.2 MG/0.75ML — 4 pens per 28-day supply
- 1.5 MG tablet, 4 MG tablet, 9 MG tablet — 60 tablets per 180-day supply (84-day)
- 25 MG tablet — 30 tablets per 30-day supply
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: At least 5% reduction in BMI.
- Renewal: For renewal (weight management): patient must have received less than 52 weeks of therapy on the maximum-tolerated dose OR achieved and maintained ≥ 5% weight loss from baseline (adults) OR ≥ 5% BMI reduction from baseline (pediatric). Pediatric patients must also maintain BMI ≥ 85th percentile at renewal. Initial BMI thresholds and 6-month lifestyle program pre-therapy requirement are not re-verified at renewal. Wegovy-specific: patient currently on and must continue low-calorie diet, increased physical activity, and behavioral modifications; must not combine with another weight loss agent or another GLP-1 RA.
Not covered when
- Combination use with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
- Combination use with another GLP-1 receptor agonist
- Any FDA labeled contraindications to the requested agent
Exceptions
- BCBS_NM_Fully_Insured_or_HIM: May be approved if patient does not have FDA labeled contraindications AND the requested indication is a rare disease AND patient has another FDA labeled indication or compendia-supported indication.
- Ohio_Fully_Insured_or_HIM_SHOP: May be approved if member resides in Ohio, plan is Fully Insured or HIM Shop (SG), no FDA labeled contraindications, AND patient has another FDA labeled or compendia-supported indication OR prescriber submits two articles from major peer-reviewed journals supporting proposed use as generally safe and effective.
Policy note: Approval duration for BCBS IL HIM/FI/ASO Cost (BBF) and BCBSMT FI & HIM is 12 months. For all other plans: initial approval is 12 months; renewal is 12 months. Wegovy 0.5mg and 1mg injections may be approved for maintenance therapy at quantity limit if patient cannot use an FDA labeled maintenance strength and has had clinical benefit. Wegovy 4mg and 9mg tablets similarly may be approved for maintenance if patient cannot use an FDA labeled maintenance strength. Quantity limit exception also available if patient has had clinical benefit on lower strength from baseline.
Policy effective May 18, 2026 · verified June 2, 2026 · source: Hcsc Weight Management Prog Sum · View policy document (PDF)