Kaiser Permanente Northwest

Does Kaiser Permanente Northwest cover Wegovy?

Quick answer · Weight Loss

Kaiser Permanente Northwest covers it only when the plan's benefit includes it on Employer / Commercial Insurance.

  • Employer / Commercial Insurance: Depends on your plan's benefit. Covered under the prescription drug benefit ONLY for Kaiser Northwest members with coverage for medications used to treat weight loss; others pay member cash price. Pediatric indication.

Last verified June 5, 2026. Policy effective February 5, 2026. Source: kp-criteria-wegovy-nw-en-commercial.pdf. How we verify this data →

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Wegovy for Weight Loss

What Kaiser Permanente Northwest requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Depends on your plan's benefit

Covered under the prescription drug benefit ONLY for Kaiser Northwest members with coverage for medications used to treat weight loss; others pay member cash price. Pediatric indication.

What you need to qualify

  • Age 12 to 17
  • BMI of 35 or higher
  • BMI at or above the 95th percentile for age and sex
  • Prior trial of another GLP-1 medication (Ozempic) for at least 90 days
  • Prior trial of phentermine, topiramate, and Qsymia for at least 3 months

Qualification pathways

You can qualify through any one of these.

Pediatric initiation for obesity (age 12-17)

All of:

  • Prescription drug benefit covers weight loss medications
  • No personal or family history of MTC or MEN 2
  • Diagnosis of class 2 or class 3 obesity
  • Age 12 to 17 years AND at least Tanner stage 2
  • Current weight and BMI documented within approximately the last 30 days
  • Currently following a diet and exercise program
  • BMI >= 35 kg/m2 OR BMI >= 120% of 95th percentile for age/sex
  • Failed adequate trial (>= 3 months) of at least two of the following OR allergy/intolerance/contraindication to ALL: phentermine, topiramate, Qsymia
  • Failed adequate trial OR has allergy/intolerance/contraindication to semaglutide (Ozempic)

Documentation to bring

  • Documentation of prescription drug insurance benefit covering weight loss medications
  • Diagnosis documentation of class 2 or class 3 obesity
  • Documentation of patient age (12-17 years) and Tanner stage >= 2
  • Current weight and BMI documented within approximately the last 30 days
  • Documentation of current diet and exercise program participation
  • Documentation of BMI >= 35 kg/m2 OR >= 120% of 95th percentile for age/sex
  • Documentation of failed adequate trial (>= 3 months) of at least two of: phentermine, topiramate, Qsymia — OR allergy/intolerance/contraindication to all
  • Documentation of failed adequate trial of semaglutide (Ozempic) OR allergy/intolerance/contraindication to Ozempic
  • Confirmation of no personal or family history of MTC or MEN 2

Approval and renewal

  • Initial approval: 12 months

Policy note: Pediatric indication for patients ages 12-17 who are at least Tanner stage 2. Diagnosis must be class 2 or class 3 obesity. BMI threshold is >= 35 kg/m2 OR >= 120% of the 95th percentile. Step therapy list does not include diethylpropion or Contrave (unlike adult criteria). Non-formulary; covered for 12 months. Continuation criteria for pediatric patients not explicitly stated in the document. An 'adequate trial' is defined as a 3-month treatment duration.

Policy effective February 5, 2026 · verified June 5, 2026 · source: kp-criteria-wegovy-nw-en-commercial.pdf

Wegovy for Heart Disease Risk Reduction

What Kaiser Permanente Northwest requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 55 to 74
  • BMI of 27 or higher
  • Prior trial of another GLP-1 medication (Ozempic)
  • Established cardiovascular disease (STEMI and Type 1 NSTEMI)
  • Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Initiation for cardiovascular risk reduction

All of:

  • No personal or family history of MTC or MEN 2
  • Patient does not have diabetes
  • BMI >= 27 kg/m2
  • Currently following a diet and exercise program
  • Age 55 to 74 years
  • History of STEMI or Type 1 NSTEMI
  • Occurrence of a STEMI or Type 1 NSTEMI while on semaglutide (Ozempic) 2 mg (does not apply to Medicare Part D patients)

Documentation to bring

  • Confirmation that patient does not have diabetes
  • Documentation of BMI >= 27 kg/m2
  • Documentation of patient age (55-74 years)
  • Documentation of history of STEMI or Type 1 NSTEMI
  • Documentation of occurrence of STEMI or Type 1 NSTEMI while on semaglutide (Ozempic) 2 mg
  • Documentation of current diet and exercise program participation
  • Confirmation of no personal or family history of MTC or MEN 2

Approval and renewal

  • Initial approval: 12 months

Not covered when

  • Active diabetes

Policy note: CV risk reduction indication requires the patient to have had a STEMI or Type 1 NSTEMI while specifically on semaglutide (Ozempic) 2 mg — this is a highly specific step-therapy requirement unique to this indication. This requirement does NOT apply to Medicare Part D patients. Non-formulary; covered for 12 months per approval. Continuation criteria for CV indication not explicitly stated in the document.

Policy effective February 5, 2026 · verified June 5, 2026 · source: kp-criteria-wegovy-nw-en-commercial.pdf

Wegovy for Liver Disease (MASH)

What Kaiser Permanente Northwest requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

  • Age 18 and older
  • BMI of 30 or higher
  • BMI of 27 or higher with a weight-related condition (T2DM, HTN, and dyslipidemia)
  • Prior trial of another GLP-1 medication (Ozempic) for at least 90 days
  • Prior trial of phentermine, diethylpropion, topiramate, Qsymia, and Contrave for at least 3 months
  • Prescribed by or in consultation with a specialist
  • Confirmed MASH diagnosis by FibroScan_VCTE, FibroScan_VCTE, MRE, and liver_biopsy, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Initiation for MASH — standard pathway

All of:

  • No personal or family history of MTC or MEN 2
  • Diagnosis of metabolic dysfunction-associated steatohepatitis (MASH)
  • Hepatology provider consulted and endorsed use
  • Age >= 18 years
  • Fibrosis stage F2 or F3 confirmed by FibroScan, ultrasound elastography, MRE, or liver biopsy within 1 year OR history of known F2/F3 currently on GLP-1 agonist without F4
  • At least one qualifying criterion from group (f) met (see any_of)
  • Failed adequate trial of semaglutide (Ozempic) (does not apply to Medicare Part D patients)
  • Not taking resmetirom
  • None of the following: regular use of MASLD-associated drugs, ALT/AST > 5x ULN from other chronic liver disease etiology, significant alcohol consumption (>=7 drinks/week females or >=14 drinks/week males), active serious disease with life expectancy < 2 years

Plus any one of:

  • BMI >= 30 kg/m2 OR (BMI 27-29 kg/m2 with T2DM, hypertension, or hyperlipidemia) AND failed adequate trial (>=3 months) of at least two of: phentermine, diethylpropion, topiramate, Qsymia, Contrave with goal of 7-10% weight loss — OR allergy/intolerance/contraindication to all (not applicable to Medicare Part D patients)
  • Failed adequate trial of formal weight loss program (without oral weight loss medication) AND hepatology provider recommends use
  • Disease refractory to weight loss of 7-10%
  • Currently taking a GLP-1 agonist

New member already taking Wegovy for MASH

All of:

  • Patient is using for MASH
  • Failed adequate trial of semaglutide (Ozempic) (does not apply to Medicare Part D patients)

Documentation to bring

  • Diagnosis documentation of metabolic dysfunction-associated steatohepatitis (MASH)
  • Documentation of hepatology provider consultation and endorsement of Wegovy use
  • Documentation of patient age >= 18 years
  • Fibrosis staging documentation (F2 or F3) by FibroScan, ultrasound elastography, MRE, or liver biopsy within the past 12 months — OR documentation of known F2/F3 history while currently on GLP-1 agonist without F4
  • Documentation satisfying at least one group (f) pathway: BMI with prior weight loss drug step therapy, OR failed formal weight loss program with hepatology recommendation, OR disease refractory to 7-10% weight loss, OR documentation of current GLP-1 agonist use
  • Documentation of failed adequate trial (>= 3 months) of semaglutide (Ozempic) — or inapplicable for Medicare Part D
  • Confirmation patient is not taking resmetirom
  • Confirmation of no regular use of MASLD-associated drugs
  • ALT/AST lab results to confirm not > 5x ULN from other chronic liver disease etiology
  • Alcohol consumption history confirming < 7 drinks/week (females) or < 14 drinks/week (males)
  • Confirmation of no active serious disease with life expectancy < 2 years
  • Confirmation of no personal or family history of MTC or MEN 2

Approval and renewal

  • Initial approval: 12 months
  • Renewal: every 12 months
  • To renew, the plan looks for Continuation requires: (1) no progression to fibrosis F4/cirrhosis; (2) no disease progression (increased fibrosis) after >= 18 months on semaglutide without further hepatology consultation; (3) no regular use of MASLD-associated drugs; (4) adherence to medication, diet, lifestyle, alcohol abstinence, and follow-up labs; (5) no active serious disease with life expectancy < 2 years; AND updated fibrosis staging by FibroScan, ultrasound elastography, MRE, or liver biopsy AND hepatology provider follow-up within 2 years after semaglutide initiation.

Not covered when

  • Fibrosis stage F4 (cirrhosis) — unless currently on GLP-1 agonist with known prior F2/F3 and no current F4
  • Currently taking resmetirom
  • Regular use of drugs associated with MASLD
  • ALT/AST > 5x ULN likely from other etiology of chronic liver disease
  • Significant alcohol consumption (>= 7 drinks/week females or >= 14 drinks/week males)
  • Active serious medical disease with likely life expectancy < 2 years

Policy note: Non-formulary; covered for 12 months per approval cycle. The Ozempic prior trial requirement and the non-Medicare Part D BMI/step-therapy pathway in criterion (f) do NOT apply to Medicare Part D patients. Alcohol limits are specified in drinks per week: 7 for females and 14 for males (approximately 98g/week and 196g/week respectively at ~14g/drink — exact gram values not stated in document). Continuation requires updated fibrosis staging AND hepatology follow-up within 2 years of semaglutide initiation. Specialist (hepatology) is required at both initiation and continuation. Continuation criteria do not re-check the Ozempic prior trial requirement or BMI/step-therapy pathways.

Policy effective February 5, 2026 · verified June 5, 2026 · source: kp-criteria-wegovy-nw-en-commercial.pdf

Why Wegovy requests get denied by Kaiser Permanente Northwest

Based on what this policy asks for. Fix these before the first submission.

  1. Your specific plan doesn't include the weight loss benefit. Coverage here is conditional on the benefit design (often an optional employer add-on), so confirm it before submitting.
  2. Wrong brand for the diagnosis. Wegovy and Ozempic are the same molecule with different approved uses; a request for Wegovy under a diagnosis that matches Ozempic is routinely denied.
  3. BMI not documented in the chart notes (or documented without a baseline weight and date).
  4. Qualifying weight-related condition not documented with its own diagnosis code.
  5. Required prior medication trials not documented.
  6. Prescriber isn't the specialist the plan requires.

If weight loss isn't covered on your plan

Kaiser Permanente Northwest has separate Wegovy policies that don't depend on the weight loss benefit:

Wegovy is also sold directly by Novo Nordisk without insurance through NovoCare.

Frequently asked questions

Does Kaiser Permanente Northwest cover Wegovy?
Kaiser Permanente Northwest covers it only when the plan's benefit includes it on Employer / Commercial Insurance.
What BMI do you need for Wegovy under Kaiser Permanente Northwest?
For weight loss on Employer / Commercial Insurance plans, Kaiser Permanente Northwest requires a BMI of 35 or higher.
How long does a Wegovy approval last with Kaiser Permanente Northwest?
Initial approvals last 12 months.
What does Kaiser Permanente Northwest require to renew Wegovy?
Continuation requires: (1) no progression to fibrosis F4/cirrhosis; (2) no disease progression (increased fibrosis) after >= 18 months on semaglutide without further hepatology consultation; (3) no regular use of MASLD-associated drugs; (4) adherence to medication, diet, lifestyle, alcohol abstinence, and follow-up labs; (5) no active serious disease with life expectancy < 2 years; AND updated fibrosis staging by FibroScan, ultrasound elastography, MRE, or liver biopsy AND hepatology provider follow-up within 2 years after semaglutide initiation.
What if my plan excludes weight loss medications?
Kaiser Permanente Northwest has separate Wegovy policies for heart disease risk reduction and liver disease (mash), which are covered on some plan types and don't depend on the weight-loss benefit. Wegovy is also available for cash through NovoCare.
How current is this information?
This page reflects Kaiser Permanente Northwest's written policy as of February 5, 2026, last verified against the source document on June 5, 2026.

Other medications under Kaiser Permanente Northwest

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes Kaiser Permanente Northwest's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.