Oscar Health coverage for Wegovy (Weight Loss)

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