Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 27 or higher
- BMI of 27 or higher with a weight-related condition (CVD, stroke, HTN, T2DM, CKD, CHD, PCOS, dyslipidemia, MASH, MASLD, idiopathic intracranial hypertension, and osteoarthritis in weight-bearing joints)
- 3 months of a documented diet and exercise program
- Prior trial of phentermine, diethylpropion, phentermine/topiramate (generic), Qsymia, naltrexone/bupropion (generic), and Contrave for at least 3 months
Qualification pathways
You can qualify through any one of these.
BMI 27 to <30 with comorbidity
All of:
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
- Age >= 12 years
- Baseline BMI 27 to <30 kg/m2
- At least ONE qualifying weight-related comorbidity (established CVD or stroke; HTN; T2DM; CKD; CHD; PCOS; dyslipidemia; NAFLD/MASH/MASLD; idiopathic intracranial hypertension; osteoarthritis in weight-bearing joints)
- Actively adhering to prescriber-documented lifestyle interventions (90 days documented with nutrition and physical activity components) and will continue lifestyle modifications
- Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication (phentermine monotherapy, diethylpropion monotherapy, generic phentermine+topiramate or Qsymia, or generic naltrexone+bupropion or Contrave)
- Documented baseline weight within past 30 days
- Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA
BMI 30 to <35
All of:
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
- Age >= 12 years
- Baseline BMI 30 to <35 kg/m2
- Actively adhering to prescriber-documented lifestyle interventions (90 days documented with nutrition and physical activity components) and will continue lifestyle modifications
- Documented intolerance, contraindication, or failure to lose and maintain >=5% body weight after 3-month trial of qualifying oral weight management medication (phentermine monotherapy, diethylpropion monotherapy, generic phentermine+topiramate or Qsymia, or generic naltrexone+bupropion or Contrave)
- Documented baseline weight within past 30 days
- Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA
BMI 35 to <40
All of:
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
- Age >= 12 years
- Baseline BMI 35 to <40 kg/m2
- Actively adhering to prescriber-documented lifestyle interventions (90 days documented with nutrition and physical activity components) and will continue lifestyle modifications
- Documented baseline weight within past 30 days
- Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA
BMI >=40
All of:
- Referred through Pharmacy Review – Injectable Weight Loss OR prescribed by Endocrinologist, Pediatrician, or Weight Management Specialist
- Age >= 12 years
- Baseline BMI >=40 kg/m2
- Currently enrolled in and/or following a lifestyle intervention program (lifestyle changes to begin at or before time of medication initiation) and will continue lifestyle modifications
- Documented baseline weight within past 30 days
- Not being used in combination with another GIP/GLP-1 RA or GLP-1 RA
Documentation to bring
- Referral through Pharmacy Review – Injectable Weight Loss OR documentation that prescriber is an Endocrinologist, Pediatrician, or Weight Management Specialist
- Patient age documentation (>=12 years)
- Documented baseline weight within past 30 days
- Documented baseline BMI
- For BMI 27 to <30: documentation of at least one qualifying weight-related comorbidity
- For BMI 27 to <35: documentation of intolerance, contraindication, or failure to lose/maintain >=5% body weight after 3-month trial of qualifying oral weight management medication
- Prescriber-documented lifestyle interventions with nutrition and physical activity components (90 days)
- Documentation that Wegovy is not being used in combination with another GLP-1 RA or GIP/GLP-1 RA
- If ordering oral tablets: documented history of trypanophobia (fear of needles)
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 Documented weight loss of at least 5% from baseline weight within the previous 6 months. Must continue prescriber-documented lifestyle interventions. If BMI is 25 to <27: 3-month x 1 reauthorization only (for deprescribing). If BMI >=27: 6-month reauthorization. Baseline BMI and prior oral weight loss drug step therapy are NOT re-verified at continuation for existing members. Make sure your starting weight and date are in the chart now — renewal is measured against it.
Not covered when
- Combination use with another GIP/GLP-1 RA or GLP-1 RA not permitted
Policy note: Oral Wegovy tablets require documented history of trypanophobia (fear of needles). Prior oral weight management drug step therapy is NOT required for BMI 35 to <40 or BMI >=40 tiers. Step therapy drugs are preferred as generics over brands (e.g., generic phentermine+topiramate preferred over brand Qsymia). Age restrictions on oral weight management step therapy drugs noted: bupropion/naltrexone combination age >=18; Contrave not indicated <18; diethylpropion age >16; phentermine age >=16; Qsymia age >=12 (max 7.5-46mg daily). Continuation: BMI 25 to <27 allows only one 3-month reauthorization for deprescribing purposes.
Policy effective June 2, 2026 · verified June 5, 2026 · source: hmo-exchange-prior-authorization-criteria-en.pdf