Premera coverage for Wegovy (Weight Loss)

What 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.

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