Employer / Commercial Insurance
Depends on your plan's benefitCovered 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