What BMI do you need for Wegovy under Oscar Health?

For weight loss on Employer / Commercial Insurance plans, Oscar Health requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.

How long does a Wegovy approval last with Oscar Health?

Initial approvals last 6 months, and renewals are granted in 6-month periods.

What does Oscar Health require to renew Wegovy?

At least 5% weight loss from the starting weight and Adults: at least 5% of baseline body weight loss achieved or sustained. Pediatrics: reduction of at least 5% of baseline BMI. Continued lifestyle modifications (reduced calorie diet, physical activity, and behavioral therapy) also required. BMI thresholds and comorbidity requirements are not re-verified at reauthorization.

Does Oscar Health cover Wegovy?

Wegovy for Weight Loss

What Oscar Health requires, by plan type. Open this indication on its own page →

Employer / Commercial Insurance

Covered with requirements

What you need to qualify

Age 12 and older
BMI of 30 or higher
BMI of 27 or higher with a weight-related condition (CVD, dyslipidemia, HTN, OSA, and T2DM)

Qualification pathways

You can qualify through any one of these.

Adult Weight Loss

All of:

Age-appropriate per FDA approval or evidence-based guidelines
Recent documentation within 1 month of baseline body weight
Medication used as adjunct to reduced-calorie diet and increased physical activity
Not used in combination with other weight loss products or similar mechanism-of-action drugs unless specified by official labeling

Plus any one of:

BMI >= 30 kg/m2
BMI >= 27 kg/m2 AND at least one weight-related comorbidity (cardiovascular disease, dyslipidemia, hypertension, obstructive sleep apnea, or type 2 diabetes mellitus)

Pediatric Weight Loss

All of:

Age-appropriate per FDA approval or evidence-based guidelines
Recent documentation within 1 month of baseline body weight
Medication used as adjunct to reduced-calorie diet and increased physical activity
BMI percentile meets criteria standardized for age and sex per FDA approval or evidence-based guidelines
Not used in combination with other weight loss products or similar mechanism-of-action drugs unless specified by official labeling

Documentation to bring

Documentation of BMI within the past 1 month (>= 30 kg/m2, or >= 27 kg/m2 with qualifying comorbidity)
Documentation of at least one weight-related comorbidity if BMI is 27-29.9 kg/m2 (e.g., cardiovascular disease, dyslipidemia, hypertension, OSA, T2DM)
Baseline (pre-treatment) body weight documented within 1 month
Confirmation that medication will be used as adjunct to reduced-calorie diet and increased physical activity
Confirmation that medication will not be combined with other weight loss products or drugs of similar mechanism

Approval and renewal

Initial approval: 6 months
Renewal: every 6 months
To renew, the plan looks for at least 5% weight loss from the starting weight and Adults: at least 5% of baseline body weight loss achieved or sustained. Pediatrics: reduction of at least 5% of baseline BMI. Continued lifestyle modifications (reduced calorie diet, physical activity, and behavioral therapy) also required. BMI thresholds and comorbidity requirements are not re-verified at reauthorization. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

Concurrent use with other weight loss products (prescription, OTC, or herbal) or co-administration with drugs of similar mechanism of action unless recommended by official labeling

Policy note: This policy covers Wegovy only for weight loss/obesity management. CV risk reduction and MASH indications are not addressed in this document. Coverage of weight loss medications varies by benefit plan; this guideline only applies to members whose plan covers obesity pharmacotherapy. The policy references Wegovy's July 2023 prescribing information. Reauthorization criteria apply to Wegovy specifically.

source: Pa policy

Why Wegovy requests get denied by Oscar Health

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

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.
BMI not documented in the chart notes (or documented without a baseline weight and date).
Qualifying weight-related condition not documented with its own diagnosis code.
Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does Oscar Health cover Wegovy?: Oscar Health covers Wegovy for weight loss with prior authorization on Employer / Commercial Insurance.
What BMI do you need for Wegovy under Oscar Health?: For weight loss on Employer / Commercial Insurance plans, Oscar Health requires a BMI of 30 or higher, or 27 or higher with a qualifying weight-related condition.
How long does a Wegovy approval last with Oscar Health?: Initial approvals last 6 months, and renewals are granted in 6-month periods.
What does Oscar Health require to renew Wegovy?: At least 5% weight loss from the starting weight and Adults: at least 5% of baseline body weight loss achieved or sustained. Pediatrics: reduction of at least 5% of baseline BMI. Continued lifestyle modifications (reduced calorie diet, physical activity, and behavioral therapy) also required. BMI thresholds and comorbidity requirements are not re-verified at reauthorization.

Other medications under Oscar Health

Does Oscar Health cover Ozempic?