Applies to Employer plans.
Covered with requirementsQualification 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
- Renewal: 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.
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: Oscar Health Employer / Commercial Insurance prior authorization policy · View policy document (PDF)