Employer / Commercial Insurance
Covered with requirementsWhat you need to qualify
- Age 12 and older
- BMI of 30 or higher
- BMI of 27 or higher with a weight-related condition (Asthma, CVD, COPD, Coronary artery disease, Dyslipidemia, HTN, Knee osteoarthritis, MASH/NAFLD, OSA, PCOS, and T2DM)
- BMI at or above the 95th percentile for age and sex
- 3 months of a documented diet and exercise program
Qualification pathways
You can qualify through any one of these.
Adult weight management (18+) — BMI >= 30
All of:
- Age >= 18 years
- BMI >= 30 kg/m2
- Trial of behavioral modification and dietary restriction for at least 3 months
- Medication used as adjunct to reduced-calorie diet and increased physical activity
- Dose limited to 2.4 mg once weekly
- Quantity limited to 4 pens per 28 days
- Not used concurrently with other weight loss medications
Adult weight management (18+) — BMI >= 27 with comorbidity
All of:
- Age >= 18 years
- BMI >= 27 kg/m2
- Trial of behavioral modification and dietary restriction for at least 3 months
- Medication used as adjunct to reduced-calorie diet and increased physical activity
- Dose limited to 2.4 mg once weekly
- Quantity limited to 4 pens per 28 days
- Not used concurrently with other weight loss medications
Plus any one of:
- Asthma
- Cardiovascular disease
- COPD
- Coronary artery disease
- Dyslipidemia
- Hypertension
- Knee osteoarthritis
- Metabolic-dysfunction associated steatotic liver disease/non-alcoholic fatty liver disease
- Obstructive sleep apnea
- Polycystic ovarian syndrome
- Type 2 diabetes mellitus
Pediatric weight management (12-17)
All of:
- Age 12-17 years
- BMI >= 95th percentile for age and sex
- Trial of behavioral modification and dietary restriction for at least 3 months
- Medication used as adjunct to reduced-calorie diet and increased physical activity
- Dose limited to 2.4 mg once weekly
- Quantity limited to 4 pens per 28 days
- Not used concurrently with other weight loss medications
Documentation to bring
- Office visit notes containing baseline body weight and BMI
- Documentation of relevant history including any weight-related comorbidities
- Documentation of dietary plan and physical activity plan
- Documentation of at least 3-month trial of behavioral modification and dietary restriction
- Medication dosage documentation
Quantity limits
- 2.4 mg — 4 pens per 28 days
Approval and renewal
- Initial approval: 7 months
- Renewal: every 12 months
- To renew, the plan looks for at least 5% weight loss from the starting weight, at least 1% reduction in BMI, Adults: >=5% baseline body weight loss after 7 months of treatment AND able to tolerate Wegovy maintenance dose of 2.4 mg once weekly AND continues adherence to reduced-calorie diet and increased physical activity. Pediatric (12-17): >=1% baseline BMI loss after 7 months AND able to tolerate maintenance dose of 1.7 mg or 2.4 mg once weekly AND continues adherence to reduced-calorie diet and increased physical activity. Non-formulary exception reviews may be approved up to 12 months, at least 28 weeks on therapy before the first renewal, and staying on a maintenance dose of at least 2.4 mg. 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 medications (phentermine, phentermine/topiramate ER, benzphetamine, diethylpropion, phendimetrazine, Alli, Contrave, liraglutide 18 mg/3 mL pen, Qsymia, Saxenda, Wegovy tablets, Xenical, Zepbound)
- All uses other than FDA-approved dosage and administration are considered investigational
- Coverage subject to benefit plan; many plans exclude weight management drugs
Policy note: This entry covers both Wegovy injection and Wegovy tablets for weight management; they share the same clinical criteria but differ in formulation/dosing. Wegovy injection: dose limited to 2.4 mg once weekly, quantity 4 pens per 28 days. Wegovy tablets: dose limited to 25 mg daily, quantity 1 tablet daily. Pediatric coverage applies to ages 12-17. Non-formulary exception reviews may be approved up to 12 months. This medical policy does not apply to Medicare Advantage.
Policy effective April 1, 2026 · verified June 3, 2026 · source: 5.01.621.pdf