Does Kaiser Permanente Northwest cover Wegovy?

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.

Qualification pathways

You can qualify through any one of these.

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 · View policy document (PDF)

Qualification pathways

You can qualify through any one of these.

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 · View policy document (PDF)

Qualification pathways

You can qualify through any one of these.

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
• Renewal: 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 · View policy document (PDF)