Applies to Employer and ACA Marketplace plans.
Depends on your plan's benefitRequires 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)