Kaiser Permanente Northwest coverage for Wegovy (Weight Loss)

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.

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