Independent Health coverage for Wegovy (Weight Loss)

What you need to qualify

• Age 12 and older
• BMI of 40 or higher
• BMI of 30 or higher with a weight-related condition (HTN, dyslipidemia, osteoarthritis, OSA, PCOS, and CVD)
• 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Baseline BMI documentation (>= 40 kg/m2 for standard pathway, or >= 30 kg/m2 for cardiovascular disease pathway)
• Documentation of at least two obesity-related comorbidities (if using standard BMI >= 40 pathway): e.g., hypertension, high cholesterol, arthritis, sleep apnea, PCOS
• Documentation of serious cardiovascular disease history (e.g., prior stroke or heart attack) if using BMI >= 30 pathway
• Documentation of in-person assessment and 6-month participation in an evidence-based lifestyle management program
• Documentation of medical reason why Zepbound cannot be used (required since Wegovy is non-preferred)

Policy note: Wegovy is non-preferred for weight loss; Zepbound is the preferred GLP-1. Wegovy is reserved for members with a medical reason not to use Zepbound. The BMI >= 30 threshold applies specifically to members with more serious cardiovascular disease such as history of stroke or heart attack. Applies to commercial plans only; Medicare Advantage, State program, and Self-funded members should check their plan documents. Detailed continuation criteria and quantity limits are not provided in this document.

source: Pa policy