HMSA Hawaii coverage for Wegovy (Weight Loss)

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Age 12 and older
BMI of 30 or higher
BMI of 27 or higher with a weight-related condition (HTN, T2DM, and dyslipidemia)
BMI at or above the 95th percentile for age and sex
6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Adult (18+) Initial Approval — BMI >= 30

All of:

Patient is 18 years of age or older
Drug will be used with a reduced calorie diet and increased physical activity to reduce excess body weight
Patient has participated in a comprehensive weight management program (behavioral modification, reduced calorie diet, increased physical activity) with continuing follow-up for at least 6 months prior to drug therapy
Baseline BMI >= 30 kg/m2

Adult (18+) Initial Approval — BMI >= 27 with comorbidity

All of:

Patient is 18 years of age or older
Drug will be used with a reduced calorie diet and increased physical activity to reduce excess body weight
Patient has participated in a comprehensive weight management program (behavioral modification, reduced calorie diet, increased physical activity) with continuing follow-up for at least 6 months prior to drug therapy
Baseline BMI >= 27 kg/m2
At least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)

Adult (18+) Continuation of Therapy

All of:

Patient is 18 years of age or older
Patient has completed at least 3 months of therapy with the requested drug at a stable maintenance dose

Plus any one of:

Patient has lost at least 5% of baseline body weight
Patient has continued to maintain their initial 5% weight loss

Pediatric (12-17) Initial Approval — Obesity

All of:

Patient is 12 to 17 years of age
Drug will be used with a reduced calorie diet and increased physical activity to reduce excess body weight
Patient has participated in a comprehensive weight management program (behavioral modification, reduced calorie diet, increased physical activity) with continuing follow-up for at least 6 months prior to drug therapy
Baseline BMI >= 95th percentile standardized for age and sex (obesity)

Pediatric (12-17) Continuation of Therapy

All of:

Patient is 12 to 17 years of age
Request is for continuation of therapy
Patient has successfully titrated to a stable maintenance dose

Plus any one of:

Patient has had a reduction from baseline BMI
Patient has continued to maintain their reduction in BMI from baseline

Documentation to bring

Baseline BMI documentation (>= 30 kg/m2 for BMI-only pathway, or >= 27 kg/m2 for comorbidity pathway)
Documentation of qualifying weight-related comorbid condition (if BMI 27-<30 pathway)
Documentation of participation in a comprehensive weight management program for at least 6 months prior to drug therapy (initial approval)
For pediatric patients: baseline BMI >= 95th percentile standardized for age and sex
For continuation (adults): documentation that patient has lost >= 5% of baseline body weight or has maintained initial 5% weight loss, after at least 3 months at stable maintenance dose
For continuation (pediatric): documentation of reduction from baseline BMI or maintenance of BMI reduction

Quantity limits

0.25 mg/0.5 mL, 0.5 mg/0.5 mL, 1 mg/0.5 mL — 2 mL (1 package of 4 pens) / 21 days; 6 mL (3 packages of 4 pens) / 63 days (84-day)
1.7 mg/0.75 mL, 2.4 mg/0.75 mL — 3 mL (1 package of 4 pens) / 21 days; 9 mL (3 packages of 4 pens) / 63 days (84-day)

Approval and renewal

Initial approval: 7 months
Renewal: every 12 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Adults (18+): Patient has lost at least 5% of baseline body weight OR has continued to maintain their initial 5% weight loss, after at least 3 months of therapy at a stable maintenance dose. Pediatric (12-17): Patient has had a reduction from baseline BMI OR has continued to maintain the reduction in BMI from baseline, after successfully titrating to a stable maintenance dose. Lifestyle program requirement is NOT re-verified at continuation. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Coadministration with other semaglutide-containing products is not recommended
Coadministration with any other GLP-1 receptor agonist is not recommended

Policy note: The 21-day supply is used for a 28-day fill period and 63-day supply is used for an 84-day fill period to allow time for refill processing. Policy number 4774-C, version UDR 08-2023 v2. Document references 'Action Required: Documentation is required for approval' for BMI, comorbidity, and weight loss outcome criteria. Pediatric indication is age 12+; adult pathway is age 18+.

verified June 5, 2026 · source: 14017_156760120