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Highmark

Does Highmark cover Wegovy?

It depends on your benefits. Highmark covers Wegovy for weight loss only when your plan includes that benefit and the policy requirements are met.

Policy documents

  • Employer and ACA Marketplace: Depends on your plan's benefit. See the qualification pathways below.

Earliest policy review June 2, 2026. How we verify · Check your exact plan

Full requirements: Wegovy for Weight Loss (2 plan types)

Applies to Employer and ACA Marketplace plans.

Depends on your plan's benefit

Requires Anti-Obesity benefit. Available to Commercial Fully Insured, Healthcare Reform (with Anti-Obesity benefit), and Commercial ASO groups electing Anti-Obesity Enhanced Weight Loss Mgmt Policy. Delaware Commercial fully-insured and Healthcare Reform plans without anti-obesity benefit may access Wegovy only via the CV risk reduction criteria in Section V.

Qualification pathways

You can qualify through any one of these.

Adolescent Initiation (Section III) - Age 12-18, Weight Loss

All of:

  • Member is 12 to 18 years of age
  • Drug used for chronic weight management (ICD-10: E66.0)
  • Baseline age, height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Member will not use Wegovy in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • 0 to < 7 months of previous therapy

Plus any one of:

  • Baseline BMI ≥ 35 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Baseline BMI ≥ 120% of the 95th percentile for age and sex (Table 1) (within 6 months prior to initiating requested medication and/or a GLP-1 medication)

Adult Initiation (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Baseline BMI ≥ 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Member will not use Wegovy in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • Member has experienced therapeutic intolerance (documented severe side effects not resolved by diet modification or dose de-escalation) or contraindication (documented allergic reaction, hypersensitivity) to plan-preferred Zepbound
  • 0 to < 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides ≥ 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member has one of the following clinical manifestations of organ dysfunction directly caused by obesity: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member has at least two of the following clinical manifestations of organ dysfunction directly caused by obesity: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Adolescent Maintenance (Section III) - Age 12+, Weight Loss

All of:

  • Member is 12 years of age or older (for Wegovy injection)
  • Drug used for chronic weight management (ICD-10: E66.0)
  • Baseline age, height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Current age, height, weight, and BMI documented
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9) - re-verified
  • Member will not use Wegovy in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of continued dietary changes and physical activity
  • Member has experienced and maintained at least a 5% BMI reduction from baseline
  • Requested dose is 1.7 mg or 2.4 mg once weekly (age ≤ 17) or 1.7 mg, 2.4 mg, or 7.2 mg (age ≥ 18), or prescriber attests titrating to age-appropriate maintenance dose
  • Member has experienced therapeutic intolerance or contraindication to plan-preferred Zepbound (if member is 18 years of age or older)
  • ≥ 7 months of previous therapy

Plus any one of:

  • Baseline BMI ≥ 35
  • Baseline BMI ≥ 120% of the 95th percentile standardized for age and sex (Table 1)

Adult Maintenance (Section IV) - Age 18+, Weight Loss

All of:

  • Member is 18 years of age or older
  • Drug used for chronic weight management (ICD-10: E66.0, E66.3)
  • Baseline height, weight, and BMI documented within 6 months of initiating requested medication and/or a GLP-1 medication
  • Current height, weight, and BMI documented
  • Baseline BMI ≥ 40 kg/m2 (within 6 months prior to initiating requested medication and/or a GLP-1 medication)
  • Member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9) - re-verified
  • Member will not use Wegovy in combination with a GLP-1 RA or GLP-1 RA combinations
  • Documentation per Table A of continued dietary changes and physical activity
  • Member has experienced and maintained ≥ 7.5% weight loss from baseline
  • Requested dose is 1.7 mg, 2.4 mg, or 7.2 mg or prescriber attests titrating to 1.7 mg, 2.4 mg, or 7.2 mg (Wegovy injection); or 25 mg once daily or titrating to it (Wegovy oral tablet)
  • Member has experienced therapeutic intolerance or contraindication to plan-preferred Zepbound
  • ≥ 7 months of previous therapy

Plus any one of:

  • Member has prediabetes (A1C 5.7%-6.4%, FPG 100-125 mg/dL, or OGTT 140-199 mg/dL) AND triglycerides ≥ 150 mg/dL AND HDL < 40 mg/dL (men) or < 50 mg/dL (women), all within 6 months
  • Member had one of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: coronary artery disease, MASH with moderate to advanced (F2-F3) liver fibrosis, myocardial infarction, stroke, peripheral arterial disease, peripheral vascular disease, or moderate to severe obstructive sleep apnea
  • Member had at least two of the following clinical manifestations of organ dysfunction directly caused by obesity at baseline: chronic severe knee or hip pain; atrial fibrillation; HFpEF with chronic fatigue or lower limb edema; HFrEF with reduced LV systolic function; hypertension; pulmonary arterial hypertension; recurrent DVT or pulmonary thromboembolic disease; idiopathic intracranial hypertension; lower limb lymphedema; male hypogonadism; microalbuminuria with reduced eGFR; PCOS/anovulation/oligo-menorrhea; recurrent or chronic urinary incontinence; reduced lung/diaphragmatic compliance; significant age-adjusted mobility limitations or ADL limitations

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • For adolescents: baseline age documented within 6 months prior to initiating requested medication
  • For adults (initiation): evidence that baseline BMI ≥ 40 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • For adolescents (initiation): evidence that baseline BMI ≥ 35 OR ≥ 120% of 95th percentile for age and sex
  • For adults: lab documentation (within 6 months) of prediabetes, triglycerides, and HDL if qualifying via metabolic comorbidity pathway
  • For adults: clinical documentation of qualifying organ dysfunction comorbidity if qualifying via that pathway
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • Prescriber attestation that member does NOT have a diagnosis of type 2 diabetes mellitus (ICD-10: E11.9)
  • Prescriber attestation that member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
  • Documentation of therapeutic intolerance (severe side effects not resolved by diet modification or dose de-escalation) or contraindication (allergic reaction, hypersensitivity) to plan-preferred Zepbound (for adults requesting Wegovy over Zepbound)
  • For maintenance: current height, weight, and BMI
  • For adolescent maintenance: documentation of ≥ 5% BMI reduction from baseline
  • For adult maintenance: documentation of ≥ 7.5% weight loss from baseline
  • For maintenance: prescriber attestation or documentation that requested dose meets maintenance dose requirements

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • Renewal: At least 5% reduction in BMI.
  • Renewal: For adolescent continuation (Section III): member must have experienced and maintained at least a 5% BMI reduction from baseline. For adult continuation (Section IV): member must have experienced and maintained ≥ 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Maintenance dose requirements must be met at continuation (Wegovy injection: 1.7 mg, 2.4 mg, or 7.2 mg for adults 18+; 1.7 mg or 2.4 mg for patients 17 and under; or prescriber attests titrating to maintenance dose. Wegovy oral tablet: 25 mg once daily or titrating to it). Step therapy to Zepbound: for adults 18+, Wegovy (Saxenda, Foundayo) requires documented intolerance or contraindication to plan-preferred Zepbound.
  • Renewal: Staying on a maintenance dose of at least 1.7 mg.

Not covered when

  • Type 2 diabetes mellitus (ICD-10: E11.9) — prescriber must attest member does NOT have T2DM diagnosis
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • Wegovy oral tablets not approved for pediatric obesity
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to semaglutide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Members with a Delaware Commercial fully-insured or Healthcare Reform plan without the anti-obesity benefit may be eligible for Wegovy coverage if criteria in Section V (CV risk reduction) are met. Wegovy for weight loss under anti-obesity benefit criteria (Sections III and IV) still requires the anti-obesity benefit.

Policy note: This policy (J-1388) is the 'Enhanced' anti-obesity policy. The 'Standard' version is J-1389. For Commercial ASO groups, the Anti-Obesity Weight Loss Mgmt Policy must = Enhanced. Zepbound is the plan-preferred agent; Wegovy requires step through Zepbound failure (intolerance or contraindication) for adults 18+. For adolescents initiating (Section III), step through Zepbound is not required. The adult weight loss criteria (Section IV) require BMI ≥ 40 with a qualifying comorbidity — this is notably higher than FDA label BMI thresholds of 27/30. Adolescent criteria (Section III) require BMI ≥ 35 OR ≥ 120% of 95th percentile. Members established on samples or paying out-of-pocket may only continue if policy criteria are met. Wegovy HD (7.2 mg) is available for adults 18+ requiring additional weight loss; it is not a recommended maintenance dose for CV risk reduction or MASH and is not available for members 17 and younger. Wegovy oral tablet is covered under weight loss criteria for adults 18+. Initiation approval = up to 7 months; maintenance approval = up to 12 months. If pancreatitis occurs, member should not switch to another GLP-1 agent.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J 1388 027 · View policy document (PDF)

Open on its own page →

Full requirements: Wegovy for Heart Disease Risk Reduction (2 plan types)

Applies to Employer and ACA Marketplace plans.

Depends on your plan's benefit

For members WITH the anti-obesity benefit, this is covered under that benefit. For Delaware Commercial fully-insured or Healthcare Reform members WITHOUT the anti-obesity benefit, coverage is available under Section V criteria. This section explicitly applies to 'members with a DE Commercial fully-insured or Healthcare Reform plan without the anti-obesity benefit only'.

Qualification pathways

You can qualify through any one of these.

CV Risk Reduction Initiation (Section V) — Delaware without anti-obesity benefit

All of:

  • Member is 18 years of age or older
  • Drug is being used for major adverse cardiovascular event risk reduction
  • Baseline height, weight, and BMI documented within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • Baseline BMI ≥ 27 kg/m2 within 6 months prior to initiating requested medication and/or a GLP-1 medication
  • Member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
  • Documentation per Table A of dietary changes and physical activity maintained for at least 6 months prior to initiation AND continued use with therapy
  • 0 to < 7 months of previous therapy

Plus any one of:

  • Member has pre-existing diagnosis of myocardial infarction (ICD-10: I21)
  • Member has pre-existing diagnosis of stroke (ICD-10: I63)
  • Member has pre-existing diagnosis of peripheral arterial disease (ICD-10: I73.9) with documentation of: intermittent claudication with ABI < 0.85 at rest, OR peripheral arterial revascularization procedure, OR amputation due to atherosclerotic disease

CV Risk Reduction — GDMT: Statin + Ezetimibe pathway

All of:

  • Member will use Wegovy as adjunct to maximally-tolerated statin therapy
  • Member will use Wegovy as adjunct to ezetimibe

CV Risk Reduction — GDMT: Statin-intolerant pathway

All of:

  • Member has experienced therapeutic failure, contraindication, or intolerance to ezetimibe monotherapy

Plus any one of:

  • While receiving at least two separate trials of different statins, member experienced statin-related rhabdomyolysis (resolved upon discontinuation) OR skeletal-related muscle symptoms (resolved upon discontinuation)
  • Member experienced CK increase to 10x ULN during any course of statin therapy
  • Member experienced LFTs increase to 3x ULN during any course of statin therapy
  • Member was hospitalized due to severe statin-related adverse event (e.g., rhabdomyolysis)

CV Risk Reduction — GDMT: PCSK9 inhibitor pathway

Plus any one of:

  • Member will use Wegovy as adjunct to a PCSK9 inhibitor (e.g., Praluent, Repatha)
  • Member has experienced therapeutic failure, contraindication, or intolerance to a PCSK9 inhibitor (e.g., Praluent, Repatha)

CV Risk Reduction — T2DM step therapy (if applicable)

All of:

  • If member has a diagnosis of Type 2 diabetes (ICD-10: E11.9): member has experienced therapeutic failure to a preferred GLP-1 RA that is FDA-approved to treat diabetes AND FDA-approved for cardiovascular risk reduction (e.g., Ozempic)

Documentation to bring

  • Baseline height, weight, and BMI within 6 months prior to initiating requested medication and/or a GLP-1 medication (must show BMI ≥ 27 kg/m2)
  • Documentation of pre-existing qualifying CVD event: myocardial infarction (ICD-10: I21), stroke (ICD-10: I63), or peripheral arterial disease (ICD-10: I73.9) with supporting documentation of ABI < 0.85 at rest, revascularization procedure, or amputation due to atherosclerotic disease
  • Documentation of current use of maximally-tolerated statin therapy AND ezetimibe, OR documentation of statin intolerance (at least two separate statin trials with rhabdomyolysis/muscle symptoms resolving upon discontinuation; OR CK > 10x ULN, LFTs > 3x ULN, or hospitalization due to severe statin-related AE) AND therapeutic failure/contraindication/intolerance to ezetimibe monotherapy
  • Documentation of current use of a PCSK9 inhibitor (e.g., Praluent, Repatha) as adjunct, OR documentation of therapeutic failure, contraindication, or intolerance to PCSK9 inhibitor
  • Table A documentation of dietary changes (e.g., provider chart notes, dietary log, nutritional counseling receipts) for at least 6 months prior to initiation
  • Table A documentation of physical activity (e.g., provider chart notes, gym membership receipts, wearable device summary, personal trainer receipts) for at least 6 months prior to initiation
  • If member has T2DM (ICD-10: E11.9): documentation of therapeutic failure to a preferred GLP-1 RA that is FDA-approved for both diabetes and CV risk reduction (e.g., Ozempic)
  • Prescriber attestation that member will not use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination
  • For maintenance: documentation that requested dose is 1.7 mg or 2.4 mg once weekly (injection) or 25 mg once daily (oral tablet), or prescriber attestation of titrating to maintenance dose

Approval and renewal

  • Initial approval: 7 months
  • Renewal: every 12 months
  • Renewal: At maintenance/continuation, the CV qualifying event (MI, stroke, or PAD), BMI ≥ 27, GDMT requirements (statin/ezetimibe and PCSK9 inhibitor), and T2DM step therapy are all re-verified. No weight loss threshold is required for continuation. Maintenance dose requirements: Wegovy injection 1.7 mg or 2.4 mg once weekly (or titrating to this); Wegovy oral tablet 25 mg once daily (or titrating to this). Note: 7.2 mg (Wegovy HD) is NOT a recommended maintenance dose for CV risk reduction.
  • Renewal: Staying on a maintenance dose of at least 1.7 mg.

Not covered when

  • Concomitant use with any GLP-1 RA or GLP-1 RA combination (e.g., with insulin, GIP RA)
  • If T2DM diagnosed: must have failed a preferred diabetes GLP-1 RA with CV indication (e.g., Ozempic) before Wegovy is approved for CV risk reduction
  • 7.2 mg dose (Wegovy HD) is NOT a recommended maintenance dose for cardiovascular risk reduction
  • Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (contraindication)
  • Previous allergic reaction or hypersensitivity to semaglutide (contraindication)
  • Pancreatitis occurring while on therapy — do not switch to another agent
  • Pregnancy

Exceptions

  • Delaware: Section V (CV risk reduction) applies ONLY to Delaware Commercial fully-insured or Healthcare Reform plan members WITHOUT the anti-obesity benefit. Members with the anti-obesity benefit would access Wegovy for CV risk reduction under standard benefit criteria.

Policy note: This section applies specifically to Delaware members without the anti-obesity benefit. The GDMT requirement is layered: member must meet BOTH the statin/ezetimibe pathway (or statin intolerance exception) AND the PCSK9 inhibitor pathway (use or prior failure). If member has T2DM, they must have failed a GLP-1 RA approved for both diabetes and CV risk reduction (example given: Ozempic) before Wegovy is approved. The CV risk reduction indication does not exclude T2DM patients but requires prior GLP-1 failure in T2DM patients. This is distinct from the weight loss indication which explicitly excludes T2DM patients. Initiation = up to 7 months; maintenance = up to 12 months.

Policy effective April 24, 2026 · verified June 2, 2026 · source: J 1388 027 · View policy document (PDF)

Open on its own page →

Full requirements: Wegovy for Liver Disease (MASH) (2 plan types)

Applies to Employer plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Initial Authorization — MASH with Wegovy

All of:

  • Member is 18 years of age or older
  • Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
  • Diagnosis of MASH (ICD-10: K75.81) documented by one of: (1) liver biopsy within previous 3 years, (2) NIT with imaging (e.g., transient elastography, VCTE/FibroScan, or MRE) within past 6 months, or (3) ELF blood test within past 6 months
  • Documentation of stage F2 or F3 fibrosis at baseline confirmed by liver biopsy or NIT
  • At least one cardiometabolic risk factor documented (see any of)
  • Prescriber documents member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
  • Prescriber documents member is currently receiving standard of care pharmacologic treatment to manage comorbid diseases (e.g., CVD, dyslipidemia, diabetes, hypertension)
  • Prescriber documents no evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
  • Prescriber documents alcohol consumption ≤20 g/day (females) or ≤30 g/day (males)
  • Member will NOT use Wegovy in combination with a GLP-1 RA or GLP-1 RA combination product (e.g., GLP-1 RA with insulin or GIP RA)

Plus any one of:

  • BMI ≥25 kg/m² (or ethnicity-adjusted equivalent, e.g., ≥23 kg/m² for Asian ethnicity) OR waist circumference ≥94 cm (males) or ≥80 cm (females) or ethnicity-adjusted equivalent
  • Fasting serum glucose ≥100 mg/dL, OR 2-hour post-prandial serum glucose ≥140 mg/dL, OR HbA1c ≥5.7%, OR diagnosis of T2DM, OR receiving treatment for T2DM
  • Plasma triglycerides ≥150 mg/dL OR receiving lipid lowering treatment
  • Plasma HDL ≤40 mg/dL (males) or ≤50 mg/dL (females) OR receiving lipid lowering treatment
  • Blood pressure ≥130/85 mmHg OR receiving treatment for hypertension

Reauthorization — MASH with Wegovy

All of:

  • Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
  • Member has experienced improvement or stabilization of fibrosis as documented by NIT
  • Member has NOT progressed to stage F4 fibrosis as documented by NIT
  • Prescriber documents member continues to utilize lifestyle interventions (weight loss if indicated, dietary changes, exercise)
  • Prescriber documents member continues to use standard of care pharmacologic treatment to manage comorbid diseases (e.g., CVD, dyslipidemia, diabetes, hypertension)
  • Prescriber documents no evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
  • Prescriber documents alcohol consumption ≤20 g/day (females) or ≤30 g/day (males)
  • Member will NOT use Wegovy in combination with a GLP-1 RA or GLP-1 RA combination product
  • Requested dose is 1.7 mg or 2.4 mg once weekly, OR prescriber attests member is titrating to 1.7 mg or 2.4 mg once weekly

Documentation to bring

  • Diagnosis of MASH (ICD-10: K75.81) confirmed by one of: liver biopsy within previous 3 years; NIT with imaging (VCTE/FibroScan or MRE) within past 6 months; or ELF blood test within past 6 months
  • Documentation of stage F2 or F3 fibrosis at baseline (by liver biopsy or NIT)
  • Documentation of at least one qualifying cardiometabolic risk factor (BMI/waist circumference, glucose/HbA1c/T2DM, triglycerides/lipid treatment, HDL levels/lipid treatment, blood pressure/hypertension treatment)
  • Prescriber attestation that member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
  • Prescriber documentation that member is currently receiving standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
  • Prescriber documentation that member has no evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
  • Prescriber documentation that member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
  • Confirmation that member will NOT use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination product
  • Prescription must be from a gastroenterologist, hepatologist, or an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
  • [Reauthorization] NIT documentation of improvement or stabilization of fibrosis and confirmation of no progression to F4 fibrosis
  • [Reauthorization] Confirmation that requested dose is 1.7 mg or 2.4 mg once weekly, or attestation that member is titrating to that dose

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • Renewal: Improvement or stabilization of fibrosis as documented by NIT; member has not progressed to stage F4 fibrosis. At reauthorization, the age criterion (≥18) and cardiometabolic risk factor criteria (criterion E) are not re-verified. Member must be at or titrating toward maintenance dose of 1.7 mg or 2.4 mg once weekly.
  • Renewal: At least 17 weeks on therapy before the first renewal.
  • Renewal: Staying on a maintenance dose of at least 1.7 mg.

Not covered when

  • Cirrhosis or evidence of hepatic decompensation
  • Hepatocellular carcinoma (HCC)
  • Alcohol consumption >20 g/day (females) or >30 g/day (males)
  • Concomitant use with GLP-1 RA or GLP-1 RA combination products (e.g., with insulin or GIP RA)
  • Moderate to severe hepatic impairment
  • Wegovy oral tablets are not covered under this policy (only single-dose pen injector)
  • Wegovy HD 7.2 mg dose is not a recommended maintenance dose for MASH and is not covered under this policy
  • Disease states outside FDA-approved indications are denied

Exceptions

  • note: An exception to some or all criteria may be granted for select members and/or circumstances based on state and/or federal regulations (Section III of Approval Criteria).

Policy note: This policy (J-1379) covers Wegovy single-dose pen injector ONLY for the MASH indication. For other Wegovy indications (weight loss, CV risk reduction), see policies J-0026, J-0184, J-1388, and J-1389. Wegovy oral tablets are NOT covered under this policy for MASH. The 0.25 mg, 0.5 mg, and 1 mg doses are initiation/escalation doses only; 1.7 mg and 2.4 mg are the approved maintenance doses for MASH. Patients may take at least 17 weeks to reach maintenance dose. Initial authorization is up to 6 months; reauthorization is up to 12 months. Healthcare Reform (HCR/Marketplace) is listed as 'Not Applicable' for Wegovy under this policy. FIB-4 alone should not be used to diagnose MASH per November 2025 AASLD guidance. Asian ethnicity BMI threshold of ≥23 kg/m² applies as a cardiometabolic risk factor criterion. Rezdiffra (resmetirom) is also covered under this policy but is not an in-scope GLP-1 medication and therefore no criteria entry is emitted for it.

Policy effective April 3, 2026 · verified July 27, 2026 · source: J 1379 008 · View policy document (PDF)

Applies to ACA Marketplace plans.

Covered with requirements

Qualification pathways

You can qualify through any one of these.

Initial Authorization – All criteria A through J must be met

All of:

  • Member is 18 years of age or older
  • Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
  • Diagnosis of MASH (ICD-10: K75.81) confirmed by one of: liver biopsy within 3 years, NIT with imaging (e.g., VCTE/FibroScan, MRE) within 6 months, or ELF blood test within 6 months
  • Documentation of stage F2 or F3 fibrosis at baseline confirmed by liver biopsy or NIT
  • At least one cardiometabolic risk factor documented (BMI ≥25 kg/m² or ethnicity-adjusted equivalent OR qualifying glucose/diabetes criterion OR qualifying triglyceride/lipid treatment criterion OR qualifying HDL criterion OR qualifying blood pressure/hypertension criterion)
  • Prescriber documents member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
  • Prescriber documents member is currently receiving standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
  • Prescriber documents member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
  • Prescriber documents member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
  • Member will NOT use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination products (e.g., GLP-1/insulin, GIP RA combinations)

Cardiometabolic Risk Factor – BMI or Waist Circumference

Plus any one of:

  • BMI ≥25 kg/m² (or ≥23 kg/m² for Asian ethnicity) or ethnicity-adjusted equivalent
  • Waist circumference ≥94 cm (males) or ≥80 cm (females) or ethnicity-adjusted equivalent

Cardiometabolic Risk Factor – Glucose/Diabetes

Plus any one of:

  • Fasting serum glucose ≥100 mg/dL
  • 2-hour post-prandial serum glucose ≥140 mg/dL
  • HbA1c ≥5.7%
  • Diagnosis of type 2 diabetes
  • Member is receiving treatment for type 2 diabetes

Cardiometabolic Risk Factor – Triglycerides/Lipid Treatment

Plus any one of:

  • Plasma triglycerides ≥150 mg/dL
  • Member is receiving lipid lowering treatment

Cardiometabolic Risk Factor – HDL

Plus any one of:

  • Plasma HDL ≤40 mg/dL for males
  • Plasma HDL ≤50 mg/dL for females
  • Member is receiving lipid lowering treatment

Cardiometabolic Risk Factor – Blood Pressure/Hypertension

Plus any one of:

  • Blood pressure ≥130/85 mmHg
  • Member is receiving treatment for hypertension

Reauthorization – All criteria A through H must be met

All of:

  • Requested medication prescribed by a gastroenterologist or hepatologist, OR by an endocrinologist/metabolic specialist in consultation with a gastroenterologist or hepatologist
  • Member has experienced improvement or stabilization of fibrosis documented by NIT
  • Member has not progressed to stage F4 fibrosis documented by NIT
  • Prescriber documents member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
  • Prescriber documents member continues to use standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
  • Prescriber documents member does not have evidence of cirrhosis, hepatic decompensation, or HCC
  • Prescriber documents member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
  • Member will NOT use Wegovy in combination with any GLP-1 RA or GLP-1 RA combination products
  • Requested dose is 1.7 mg or 2.4 mg once weekly, OR prescriber attests member is titrating to 1.7 mg or 2.4 mg once weekly

Documentation to bring

  • Documentation of MASH diagnosis (ICD-10: K75.81) confirmed by one of: liver biopsy within prior 3 years, NIT with imaging (VCTE/FibroScan or MRE) within prior 6 months, or ELF blood test within prior 6 months
  • Documentation of stage F2 or F3 fibrosis at baseline (via liver biopsy or NIT)
  • Documentation of at least one qualifying cardiometabolic risk factor (BMI, waist circumference, glucose/diabetes, triglycerides/lipid treatment, HDL, or blood pressure/hypertension treatment)
  • Prescriber attestation that member is utilizing lifestyle interventions (weight loss if indicated, dietary changes, exercise)
  • Prescriber attestation that member is currently receiving standard of care pharmacologic treatment for comorbid diseases (CVD, dyslipidemia, diabetes, hypertension)
  • Prescriber attestation that member does not have evidence of cirrhosis, hepatic decompensation, or hepatocellular carcinoma (HCC)
  • Prescriber attestation that member's alcohol consumption is ≤20 g/day (females) or ≤30 g/day (males)
  • Prescriber attestation that Wegovy will NOT be used in combination with any GLP-1 RA or GLP-1 RA combination product
  • Prescription must be from gastroenterologist or hepatologist, or endocrinologist/metabolic specialist in consultation with gastroenterologist or hepatologist
  • [Reauthorization only] NIT documentation of improvement or stabilization of fibrosis
  • [Reauthorization only] NIT documentation that member has not progressed to stage F4 fibrosis
  • [Reauthorization only] Prescriber attestation that requested dose is 1.7 mg or 2.4 mg once weekly, or that member is titrating to that dose

Quantity limits

  • 0.25mg, 0.5mg, 1mg, 1.7mg, 2.4mg

Approval and renewal

  • Initial approval: 6 months
  • Renewal: every 12 months
  • Renewal: Improvement or stabilization of fibrosis documented by NIT; member has not progressed to stage F4 fibrosis as documented by NIT. At reauthorization, cardiometabolic risk factor criteria (BMI, glucose, lipids, BP) are NOT re-verified. Age criterion is NOT re-verified. Wegovy-specific: member must be at dose 1.7 mg or 2.4 mg once weekly, or prescriber attests member is titrating to that dose.
  • Renewal: At least 17 weeks on therapy before the first renewal.
  • Renewal: Staying on a maintenance dose of at least 1.7 mg.

Not covered when

  • Cirrhosis or evidence of hepatic decompensation
  • Hepatocellular carcinoma (HCC)
  • Alcohol consumption exceeding ≤20 g/day (females) or ≤30 g/day (males)
  • Concomitant use with any GLP-1 RA or GLP-1 RA combination product (e.g., with insulin, GIP RA)
  • Decompensated cirrhosis or moderate to severe hepatic impairment
  • Wegovy oral tablets (not approved for MASH under this policy; only single-dose pen injectors 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, 2.4 mg are covered)
  • Wegovy HD 7.2 mg dose (not a recommended maintenance dose for MASH)
  • F4 fibrosis (cirrhosis) — not covered; policy covers F2-F3 only
  • Healthcare Reform (HCR) members: policy states Not Applicable for HCR for Wegovy MASH

Exceptions

  • note: An exception to some or all criteria may be granted for select members and/or circumstances based on state and/or federal regulations (per Section III of Approval Criteria).

Policy note: 1. This policy (J-1379) covers Wegovy ONLY for the MASH indication. For other Wegovy indications (weight loss, CV risk reduction), see policies J-0026, J-0184, J-1388, and J-1389. 2. Maintenance dose for MASH is 1.7 mg or 2.4 mg once weekly; 0.25 mg, 0.5 mg, and 1 mg are titration doses only and not approved maintenance doses. Patients may take at least 17 weeks to reach maintenance dose. 3. Wegovy HD 7.2 mg is only for patients requiring additional weight loss and is not a recommended maintenance dose for MASH. 4. Initial authorization duration is up to 6 months; reauthorization is up to 12 months. 5. FIB-4 alone should NOT be used to diagnose MASH per November 2025 AASLD guidance. 6. MASH confirmation via NIT with imaging or ELF blood test must be within 6 months; liver biopsy within 3 years. 7. The cardiometabolic risk factor criteria reference ethnicity-adjusted BMI (≥23 kg/m² for Asian ethnicity) and waist circumference equivalents. 8. Healthcare Reform line of business is listed as 'Not Applicable' for Wegovy under this policy.

Policy effective April 3, 2026 · verified June 2, 2026 · source: J 1379 008 · View policy document (PDF)

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If weight loss isn't covered on your plan

Highmark has separate Wegovy policies that don't depend on that benefit:

Questions people ask
Does Highmark cover Wegovy?
It depends on your benefits. Highmark covers Wegovy for weight loss only when your plan includes that benefit and the policy requirements are met.
How long does a Wegovy approval last with Highmark?
Weight Loss — Applies to Employer and ACA Marketplace plans. Initial approval: 7 months. Renewal: every 12 months. Heart Disease Risk Reduction — Applies to Employer and ACA Marketplace plans. Initial approval: 7 months. Renewal: every 12 months. Liver Disease (MASH) — Applies to Employer plans. Initial approval: 6 months. Renewal: every 12 months. Liver Disease (MASH) — Applies to ACA Marketplace plans. Initial approval: 6 months. Renewal: every 12 months.
What does Highmark require to renew Wegovy?
Weight Loss — Applies to Employer and ACA Marketplace plans. At least 5% reduction in BMI. For adolescent continuation (Section III): member must have experienced and maintained at least a 5% BMI reduction from baseline. For adult continuation (Section IV): member must have experienced and maintained ≥ 7.5% weight loss from baseline. T2DM exclusion (no E11.9 diagnosis) is re-verified at continuation. Maintenance dose requirements must be met at continuation (Wegovy injection: 1.7 mg, 2.4 mg, or 7.2 mg for adults 18+; 1.7 mg or 2.4 mg for patients 17 and under; or prescriber attests titrating to maintenance dose. Wegovy oral tablet: 25 mg once daily or titrating to it). Step therapy to Zepbound: for adults 18+, Wegovy (Saxenda, Foundayo) requires documented intolerance or contraindication to plan-preferred Zepbound. Staying on a maintenance dose of at least 1.7 mg. Heart Disease Risk Reduction — Applies to Employer and ACA Marketplace plans. At maintenance/continuation, the CV qualifying event (MI, stroke, or PAD), BMI ≥ 27, GDMT requirements (statin/ezetimibe and PCSK9 inhibitor), and T2DM step therapy are all re-verified. No weight loss threshold is required for continuation. Maintenance dose requirements: Wegovy injection 1.7 mg or 2.4 mg once weekly (or titrating to this); Wegovy oral tablet 25 mg once daily (or titrating to this). Note: 7.2 mg (Wegovy HD) is NOT a recommended maintenance dose for CV risk reduction. Staying on a maintenance dose of at least 1.7 mg. Liver Disease (MASH) — Applies to Employer plans. Improvement or stabilization of fibrosis as documented by NIT; member has not progressed to stage F4 fibrosis. At reauthorization, the age criterion (≥18) and cardiometabolic risk factor criteria (criterion E) are not re-verified. Member must be at or titrating toward maintenance dose of 1.7 mg or 2.4 mg once weekly. At least 17 weeks on therapy before the first renewal. Staying on a maintenance dose of at least 1.7 mg. Liver Disease (MASH) — Applies to ACA Marketplace plans. Improvement or stabilization of fibrosis documented by NIT; member has not progressed to stage F4 fibrosis as documented by NIT. At reauthorization, cardiometabolic risk factor criteria (BMI, glucose, lipids, BP) are NOT re-verified. Age criterion is NOT re-verified. Wegovy-specific: member must be at dose 1.7 mg or 2.4 mg once weekly, or prescriber attests member is titrating to that dose. At least 17 weeks on therapy before the first renewal. Staying on a maintenance dose of at least 1.7 mg.
How current is this information?
The oldest review date among the policies on this page is June 2, 2026. Each policy's effective and verification dates appear with its requirements. Confirm current benefits with your plan.

Also under Highmark: Zepbound

Wegovy under other plans: Capital BlueCross, Delaware Medicaid, Elevance Health, EmblemHealth, Excellus BCBS, Independence Blue Cross, Independent Health, Molina Healthcare

All insurance plans · All medications

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