Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (HTN, CAD, T2DM, dyslipidemia, and OSA)
- BMI at or above the 95th percentile for age and sex
Qualification pathways
You can qualify through any one of these.
Adult patients (18+) with obesity
All of:
- Member is 18 years of age or older
- Documentation (e.g., chart note) confirming BMI >= 30 kg/m2
- Drug used as adjunct to lifestyle modification
- No concurrent use of any other GLP-1 receptor agonist (e.g., Ozempic, Rybelsus, Trulicity, Victoza)
Adult patients (18+) with overweight and comorbidity
All of:
- Member is 18 years of age or older
- Documentation (e.g., chart note) confirming BMI >= 27 kg/m2
- One or more comorbidities (e.g., hypertension, coronary artery disease, type 2 diabetes mellitus, dyslipidemia, or obstructive sleep apnea)
- Drug used as adjunct to lifestyle modification
- No concurrent use of any other GLP-1 receptor agonist (e.g., Ozempic, Rybelsus, Trulicity, Victoza)
Pediatric patients (12-17 years) with obesity
All of:
- Member is 12 to 17 years of age
- Documentation (e.g., chart note) confirming initial BMI at the 95th percentile or greater for age and sex (obesity)
- Drug used as adjunct to lifestyle modification
- No concurrent use of any other GLP-1 receptor agonist (e.g., Ozempic, Rybelsus, Trulicity, Victoza)
Documentation to bring
- Chart note confirming BMI >= 30 kg/m2 OR BMI >= 27 kg/m2 with at least one qualifying comorbidity (adults 18+)
- Chart note confirming BMI at 95th percentile or greater for age and sex (pediatric patients 12-17)
- Documentation confirming no concurrent use of another GLP-1 receptor agonist
- For reauthorization: chart note confirming weight loss >= 5% from baseline body weight
Approval and renewal
- Initial approval: 6 months
- Renewal: every 6 months
- To renew, the plan looks for at least 5% weight loss from the starting weight and Weight loss of >= 5% from baseline body weight required for reauthorization. Concurrent GLP-1 restriction and lifestyle modification adjunct use are re-verified. Initial BMI/comorbidity criteria are NOT re-checked at reauthorization. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Personal or family history of medullary thyroid carcinoma (MTC) - contraindication per black box warning
- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) - contraindication per black box warning
- Concurrent use of any other GLP-1 receptor agonist
Policy note: Policy is titled 'Weight Loss Agents' (Rx.01.94). Wegovy is listed only under chronic weight management for weight loss indication in this document. No CV risk reduction, MASH, or other indications are covered in this policy. Pediatric approval (ages 12-17) requires BMI at 95th percentile or greater for age and sex per Cole Criteria. No quantity limits specified in this document. Initial authorization is 7 months; reauthorization is 6 months.
source: Pa policy