Priority Health

Does Priority Health cover Wegovy?

Quick answer · Weight Loss

Priority Health covers Wegovy for weight loss with prior authorization on Medicaid.

  • Medicaid: Covered (preferred drug). BMI of 30 or higher

Last verified June 10, 2026. Policy effective May 1, 2025. Source: medicaid-rx-pa-criteria.pdf. How we verify this data →

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Wegovy for Weight Loss

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

Medicaid

Covered (preferred drug)

What you need to qualify

  • Age 12 and older
  • BMI of 30 or higher
  • BMI of 27 or higher with a weight-related condition (T2DM, OSA, HTN, dyslipidemia, and coronary_artery_disease)
  • BMI at or above the 95th percentile for age and sex

Qualification pathways

You can qualify through any one of these.

Pediatric (age 12 to <18): Obesity

All of:

  • Patient age >= 12 years
  • Prescriber attests patient will not use more than one weight loss medication concurrently
  • Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
  • Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
  • Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
  • Prescriber attests medication is part of a total treatment plan including diet and exercise
  • Prescriber attests patient has been informed weight may return with cessation of medication
  • BMI >= 95th percentile for age and sex per CDC growth charts

Pediatric (age 12 to <18): Overweight with comorbidity

All of:

  • Patient age >= 12 years
  • Prescriber attests patient will not use more than one weight loss medication concurrently
  • Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
  • Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
  • Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
  • Prescriber attests medication is part of a total treatment plan including diet and exercise
  • Prescriber attests patient has been informed weight may return with cessation of medication
  • BMI in the 85th-94th percentile for age and sex per CDC growth charts

Plus any one of:

  • Diabetes
  • Sleep apnea
  • Hypertension
  • Dyslipidemia

Adult (age >= 18): Obesity

All of:

  • Patient age >= 18 years
  • Prescriber attests patient will not use more than one weight loss medication concurrently
  • Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
  • Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
  • Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
  • Prescriber attests medication is part of a total treatment plan including diet and exercise
  • Prescriber attests patient has been informed weight may return with cessation of medication
  • Initial BMI >= 30 kg/m2

Adult (age >= 18): Overweight with comorbidity

All of:

  • Patient age >= 18 years
  • Prescriber attests patient will not use more than one weight loss medication concurrently
  • Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
  • Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
  • Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
  • Prescriber attests medication is part of a total treatment plan including diet and exercise
  • Prescriber attests patient has been informed weight may return with cessation of medication
  • Initial BMI >= 27 kg/m2 and < 30 kg/m2

Plus any one of:

  • Hypertension
  • Coronary artery disease
  • Diabetes
  • Dyslipidemia
  • Sleep apnea

Documentation to bring

  • Prescriber attestation that patient will not use more than one weight loss medication in this drug class concurrently
  • Prescriber attestation that patient will not use an anti-obesity GLP-1 agonist (Wegovy, Saxenda, or Zepbound) concurrently with a DPP4 inhibitor
  • Documentation of patient age
  • For patients age 12 to <18: baseline BMI percentile per CDC growth charts (>=95th percentile OR 85th-94th percentile with qualifying comorbidity)
  • For patients age >=18: baseline BMI >= 30 kg/m2, OR >= 27 kg/m2 with qualifying comorbidity
  • If eating disorder present: prescriber attestation that treatment has been optimized and confirms safety and appropriateness
  • Prescriber attestation that metabolic or other reasons for obesity have been ruled out or diagnosed and treated
  • Prescriber attestation of absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
  • Prescriber attestation that medication is part of a total treatment plan including diet and exercise
  • Prescriber attestation that patient has been informed weight may return with cessation of medication
  • For renewal (adults): clinical documentation of weight loss >= 5% from baseline
  • For renewal (pediatric): clinical documentation of maintained or improved BMI percentile per CDC growth charts

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 (>=18): documented weight loss of >=5% from baseline weight at initiation of therapy. Pediatric (12 to <18): maintained or improved BMI percentile per CDC growth charts from baseline. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Lactation
  • Personal or family history of medullary thyroid cancer
  • Personal or family history of multiple endocrine neoplasia type II
  • Concurrent use of more than one weight loss medication in this drug class
  • Concurrent use with DPP4 inhibitor
  • Pregnancy

Policy note: MDHHS recommends prescribers consider the benefits of a diabetes prevention program for their patients. For patients with an eating disorder, prescriber must attest that treatment has been optimized and confirm safety and appropriateness. Duration of approval is 6 months for both initial and renewal.

Policy effective May 1, 2025 · verified June 10, 2026 · source: medicaid-rx-pa-criteria.pdf

Wegovy for Heart Disease Risk Reduction

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

Medicaid

Covered (preferred drug)

What you need to qualify

  • Age 18 and older
  • BMI of 27 or higher
  • Established cardiovascular disease (MI, stroke, and PAD)

Qualification pathways

You can qualify through any one of these.

Adult (age >= 18): CV risk reduction with BMI >= 27 and prior CV event

All of:

  • Patient age >= 18 years
  • Initial BMI >= 27 kg/m2
  • Prescriber attests patient will not use more than one weight loss medication concurrently
  • Prescriber attests patient will not use an anti-obesity GLP-1 agonist concurrently with a DPP4 inhibitor
  • Prescriber attests metabolic or other reasons for obesity have been ruled out or diagnosed and treated
  • Prescriber attests absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
  • Prescriber attests medication is part of a total treatment plan including diet and exercise
  • Prescriber attests patient has been informed weight may return with cessation of medication

Plus any one of:

  • Prior myocardial infarction
  • Prior stroke
  • Peripheral arterial disease

Documentation to bring

  • Prescriber attestation that patient will not use more than one weight loss medication in this drug class concurrently
  • Prescriber attestation that patient will not use an anti-obesity GLP-1 agonist (Wegovy, Saxenda, or Zepbound) concurrently with a DPP4 inhibitor
  • Documentation of patient age >= 18 years
  • Documentation of baseline BMI >= 27 kg/m2
  • Documentation of qualifying prior cardiovascular event (prior MI, prior stroke, or peripheral arterial disease)
  • If eating disorder present: prescriber attestation that treatment has been optimized and confirms safety and appropriateness
  • Prescriber attestation that metabolic or other reasons for obesity have been ruled out or diagnosed and treated
  • Prescriber attestation of absence of contraindications (pregnancy, lactation, personal or family history of medullary thyroid cancer or MEN type II)
  • Prescriber attestation that medication is part of a total treatment plan including diet and exercise
  • Prescriber attestation that patient has been informed weight may return with cessation of medication
  • For renewal: clinical documentation of weight loss >= 5% from baseline

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 (>=18): documented weight loss of >=5% from baseline weight at initiation of therapy. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

  • Lactation
  • Personal or family history of medullary thyroid cancer
  • Personal or family history of multiple endocrine neoplasia type II
  • Concurrent use of more than one weight loss medication in this drug class
  • Concurrent use with DPP4 inhibitor
  • Pregnancy

Policy note: CV risk reduction pathway is carved out from the standard BMI-with-comorbidity pathway; listed as a distinct qualifying condition: 'This medication is being prescribed for cardiovascular risk reduction in members with prior myocardial infarction, prior stroke, or peripheral arterial disease (Wegovy)'. Duration of approval is 6 months for both initial and renewal.

Policy effective May 1, 2025 · verified June 10, 2026 · source: medicaid-rx-pa-criteria.pdf

Why Wegovy requests get denied by Priority Health

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

  1. 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.
  2. BMI not documented in the chart notes (or documented without a baseline weight and date).
  3. Qualifying weight-related condition not documented with its own diagnosis code.
  4. Baseline weight wasn't recorded at the start, so the required weight loss can't be shown at renewal.

Frequently asked questions

Does Priority Health cover Wegovy?
Priority Health covers Wegovy for weight loss with prior authorization on Medicaid.
What BMI do you need for Wegovy under Priority Health?
For weight loss on Medicaid plans, Priority 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 Priority Health?
Initial approvals last 6 months, and renewals are granted in 6-month periods.
What does Priority Health require to renew Wegovy?
At least 5% weight loss from the starting weight and Adults (>=18): documented weight loss of >=5% from baseline weight at initiation of therapy. Pediatric (12 to <18): maintained or improved BMI percentile per CDC growth charts from baseline.
How current is this information?
This page reflects Priority Health's written policy as of May 1, 2025, last verified against the source document on June 10, 2026.

Other medications under Priority Health

Wegovy coverage under other plans

All insurance plans · All medications

This page summarizes Priority Health's written prior-authorization policy. It is not a guarantee of coverage; plans vary by employer and benefit design. Verify with your plan before relying on it.