Horizon BCBS coverage for Wegovy (Weight Loss)

Employer / Commercial Insurance

Depends on your plan's benefit

Obesity must NOT be restricted from coverage under the patient's benefit

What you need to qualify

BMI of 35 or higher
6 months of a documented diet and exercise program
Prior trial of another GLP-1 medication (liraglutide (Saxenda)) for at least 90 days
Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Adult weight management (Wegovy)

All of:

Obesity is NOT restricted from coverage under the patient's benefit
Patient does NOT have Type 2 diabetes
Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
Patient is an adult (> 18 years of age)
BMI >= 35 kg/m2 with at least one comorbidity (e.g., hypertension, OSA, CVD, dyslipidemia)
Weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for minimum 6 months (documentation required within last 6 months)
Baseline weight and BMI obtained during in-office visit within last 30 days
Active participation in in-person, digital, or telehealth weight management program
Patient starting therapy OR has achieved and maintained weight loss >= 5% from baseline
Will NOT use in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
Will NOT use in combination with another GLP-1 receptor agonist
No FDA labeled contraindications to requested agent
Currently on low-calorie diet, increased physical activity, and behavioral modifications

Plus any one of:

Patient has NOT tried a targeted weight loss agent (e.g., Saxenda, Wegovy, Zepbound) in the past 12 months
Patient has tried a targeted weight loss agent in the past 12 months AND prescriber anticipates success with repeating therapy
Inadequate response to 3-month trial of liraglutide (Saxenda generic) not expected to occur with Wegovy
Intolerance or hypersensitivity to liraglutide (Saxenda generic) not expected to occur with Wegovy
FDA labeled contraindication to liraglutide (Saxenda generic) not expected to occur with Wegovy

Pediatric weight management (Wegovy, ages 12 to <18)

All of:

Obesity is NOT restricted from coverage under the patient's benefit
Patient does NOT have Type 2 diabetes
Patient is new to therapy, new to Prime, or attempting a repeat weight loss course of therapy
Patient is pediatric (12 to less than 18 years of age)
Weight loss regimen of low-calorie diet, increased physical activity, and behavioral modifications for minimum 6 months (documentation required within last 6 months)
Baseline weight and BMI obtained during in-office visit within last 30 days
Active participation in in-person, digital, or telehealth weight management program
Patient starting therapy OR has achieved and maintained BMI reduction >= 5% from baseline
Will NOT use in combination with another weight loss agent
Will NOT use in combination with another GLP-1 receptor agonist
No FDA labeled contraindications to requested agent
Currently on low-calorie diet, increased physical activity, and behavioral modifications

Plus any one of:

BMI >= 95th percentile for age and sex
BMI >= 30 kg/m2
BMI >= 85th percentile for age and sex AND at least one weight-related comorbidity/risk factor (e.g., hypertension, dyslipidemia, T2DM, OSA)
Patient has NOT tried a targeted weight loss agent in the past 12 months
Patient has tried a targeted weight loss agent in the past 12 months AND prescriber anticipates success with repeating therapy
Inadequate response to 3-month trial of liraglutide (Saxenda generic) not expected to occur with Wegovy
Intolerance or hypersensitivity to liraglutide (Saxenda generic) not expected to occur with Wegovy
FDA labeled contraindication to liraglutide (Saxenda generic) not expected to occur with Wegovy

Documentation to bring

Documentation that obesity is NOT restricted from coverage under patient's benefit
Documentation confirming patient does NOT have Type 2 diabetes
Baseline weight and BMI from in-office visit within the last 30 days
Documentation of active participation in lifestyle changes within last 6 months (e.g., food diary, exercise log, step counter report, gym attendance log, fitness tracker printout)
Medical records confirming active participation in in-person, digital, or telehealth weight management program
Medical records supporting prior liraglutide (Saxenda generic) trial (inadequate response, intolerance, or contraindication) OR documentation that patient has not tried a targeted weight loss agent in past 12 months OR documentation supporting repeat therapy with prescriber anticipation of success
MedWatch form if intolerance/hypersensitivity to liraglutide is the reason for step-through

Quantity limits

0.25mg, 0.5mg, 1mg — 8 pens per 180 days (84-day)
1.7mg, 2.4mg — 4 pens per 28 days

Approval and renewal

Initial approval: 3 months
Renewal: every 6 months
To renew, the plan looks for at least 5% weight loss from the starting weight, at least 5% reduction in BMI, and Adult: weight loss >= 5% from baseline OR weight loss >= 1 lb/week from baseline; AND baseline BMI >= 35 and current BMI >= 35 (measured within last 30 days). Pediatric (12-17): BMI reduction >= 5% from baseline AND current BMI >= 85th percentile for age and sex. Failed efficacy precludes future coverage of same drug. Obesity benefit restriction and T2DM exclusion are re-verified at renewal. BMI must be obtained during in-office visit within last 30 days. Continued active participation in weight management program required. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Type 2 diabetes (T2DM patients excluded from weight_loss indication)
Concomitant use with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical)
Concomitant use with another GLP-1 receptor agonist
Any FDA labeled contraindications to the requested agent

Policy note: Quantity limits for 0.25mg, 0.5mg, and 1mg are 8 pens per 180 days supply. Quantity limits for 1.7mg and 2.4mg are 4 pens per 28 days. Initial approval duration is 3 months for obesity indication. Renewal approval is 6 months. Step-therapy requires prior liraglutide (Saxenda generic) trial OR documented intolerance/contraindication. Policy title is 'GLP-1 Agonist for Non-Diabetic Use.' For renewal: adult continuation requires weight loss >= 5% from baseline OR >= 1 lb/week, AND baseline BMI >= 35 with current BMI >= 35 (within 30 days). Failed continuation criteria precludes future coverage of same drug.

verified June 5, 2026 · source: glp1-for-non-diabetic-use.pdf