Kaiser Permanente Northern California coverage for Wegovy (Weight Loss)

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, dyslipidemia, CVD, CAD, OSA, osteoarthritis_of_knees, PCOS, NASH_NAFLD, asthma, and COPD)
• BMI of 27.5 or higher for patients of Asian descent
• 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.

Documentation to bring

• Documentation of patient age
• Baseline BMI documentation: >= 30 kg/m² (general adult), or >= 27.5 kg/m² (Asian adult), or >= 27 kg/m² with qualifying comorbidity (general adult), or >= 25 kg/m² with qualifying comorbidity (Asian adult), or >= 95th percentile for age/sex (adolescents 12–17)
• Documentation of at least one weight-related comorbidity if using lower BMI threshold (HTN, T2DM, dyslipidemia, CVD, CAD, sleep apnea, osteoarthritis of knees, PCOS, NASH/NAFLD, asthma, or COPD)
• Attestation of active enrollment in an exercise and caloric reduction program
• Confirmation of no concurrent GLP-1 receptor agonist or GLP-1/GIP receptor agonist use
• For renewal: documentation of >= 5% weight loss from baseline body weight (adults) or >= 5% BMI reduction from baseline (adolescents 12–17)

Approval and renewal

• To renew, the plan looks for at least 5% weight loss from the starting weight, at least 5% reduction in BMI, and Renewal requires: (1) no concurrent GLP-1 or GLP-1/GIP agonist; (2) for adults (>=18): re-verification of baseline BMI eligibility criteria AND at least 5% weight loss of baseline body weight achieved or maintained; (3) for adolescents (12–17): at least 5% reduction of baseline BMI achieved or maintained. Note: the 5% threshold for adults is 5% of baseline body weight; for adolescents it is 5% of baseline BMI. Active lifestyle program enrollment is NOT explicitly re-verified at renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Concurrent use of another GLP-1 receptor agonist (liraglutide, exenatide, semaglutide other products) or GLP-1/GIP receptor agonist (tirzepatide products)

Policy note: The weight loss indication covers both adults (age >= 18) and adolescents (age 12–17). For Asian adults, bmi_min_asian = 27.5 kg/m² (no comorbidity required) or 25 kg/m² with comorbidity. For renewal, adults must re-verify both BMI eligibility AND 5% weight loss; adolescents only need 5% BMI reduction. The continuation_weight_loss_percent (5%) and continuation_bmi_reduction_percent (5%) reflect different metrics: 5% body weight for adults, 5% of baseline BMI for adolescents. Pregnancy/Type 1 diabetes/bariatric surgery exclusions are not explicitly stated in this document but are standard; marked false here since not explicitly documented.

Policy effective June 1, 2026 · verified June 5, 2026 · source: Standard-Commercial-Guidelines-6-1-26-EXCERPTED.pdf