Does Regence cover Wegovy?

Coverage requires that the member benefit contract allows for coverage of medications for weight loss in obesity/overweight; weight loss must NOT be excluded from the pharmacy benefit

What you need to qualify

• Age 12 and older
• BMI of 30 or higher
• BMI of 27 or higher with a weight-related condition (HTN, dyslipidemia, T2DM, pre-diabetes, insulin_resistance, OSA, CVD, and symptomatic_arthritis_lower_extremities)
• BMI at or above the 95th percentile for age and sex
• 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Clinical documentation (e.g., chart notes) confirming BMI >= 30 kg/m2 (adults with obesity) OR BMI >= 27 kg/m2 with at least one weight-related comorbid condition (adults overweight) OR BMI >= 95th percentile for age and sex (pediatrics 12-17)
• Attestation that medication will be used concomitantly with lifestyle modification
• For continuation: attestation of >= 5% body weight reduction from pretreatment baseline OR documentation that dose is currently being titrated upwards (adults); BMI reduction OR titration upward documentation (pediatrics)

Quantity limits

• all strengths - injection — 4 pens per 28 days
• all strengths - tablet — 30 tablets per 30 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and Adults (>=18 years): >= 5% body weight reduction from pretreatment baseline OR dose currently being titrated upwards. Pediatrics (12-17 years): reduction from pretreatment baseline BMI OR dose currently being titrated upwards. Attestation required that medication continues to be used with lifestyle modification. Benefit contract coverage eligibility re-verified at each renewal. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Co-administration with other weight loss medications (Contrave, Qsymia, or other GLP-1 agents in this policy) considered investigational
• Used for type 2 diabetes without obesity or overweight — considered not medically necessary
• Diabetic ketoacidosis (DKA)
• Type 1 diabetes

Policy note: Policy dru787.5 covers only GLP-1 formulations NOT specifically approved for diabetes. Wegovy tablets (oral semaglutide) authorized at parity with Wegovy injection. Wegovy HD (semaglutide) added 6/4/2026 at parity. Coverage for weight loss is explicitly gated on member benefit contract allowing coverage for weight loss medications. Pediatric use (12-17 years) is explicitly allowed for Wegovy. T2DM patients without obesity/overweight are excluded. Policy does not apply to Mounjaro or Ozempic (covered under separate policy dru750). BMI percentile threshold of 95th percentile applies to pediatric patients aged 12-17 years.

Policy effective July 15, 2026 · verified July 16, 2026 · source: dru787reg.pdf

Coverage requires that the member benefit contract allows for coverage of medications for weight loss in obesity/overweight. Not coverable when the member benefit contract excludes obesity/overweight treatments.

What you need to qualify

• Age 12 and older
• BMI of 30 or higher
• BMI of 27 or higher with a weight-related condition (HTN, dyslipidemia, T2DM, pre-diabetes, insulin_resistance, OSA, CVD, and symptomatic_arthritis_lower_extremities)
• BMI at or above the 95th percentile for age and sex
• 6 months of a documented diet and exercise program

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Clinical documentation (such as chart notes) confirming BMI >= 30 kg/m2 (obesity) OR BMI >= 27 kg/m2 with at least one weight-related comorbid condition
• For pediatric patients: BMI >= 95th percentile standardized for age and sex (Wegovy)
• Attestation that medication will be used with lifestyle modification (dietary/caloric restriction, exercise, weight management program, nutritional counseling, behavioral therapy)
• Verification that member benefit contract allows coverage of medications for weight loss in obesity/overweight

Quantity limits

• all strengths - injection — 4 pens/28 days
• all strengths - tablet — 30 tablets/30 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for at least 5% weight loss from the starting weight and Adults (>=18 years): >= 5% body weight reduction from pretreatment baseline OR dose currently being titrated upwards. Pediatrics (12-17 years): reduction from pretreatment baseline BMI OR dose currently being titrated upwards. Member benefit contract must continue to allow coverage for weight loss in obesity/overweight. Attestation required that medication will continue to be used with lifestyle modification. Make sure your starting weight and date are in the chart now — renewal is measured against it.

Not covered when

• Co-administration with other medications for obesity or overweight (including Contrave, Qsymia) is considered investigational and not covered
• Use for type 2 diabetes without obesity or overweight is considered not medically necessary
• Central or mixed sleep apnea
• Cheyne-Stokes respiration
• OSA with major craniofacial abnormalities
• Type 1 diabetes

Policy note: Policy dru787 covers non-diabetic indications only. Mounjaro and Ozempic are addressed in a separate policy (dru750). Only Wegovy (semaglutide) and liraglutide generic/Saxenda are coverable for obesity in pediatrics (ages 12-17). Coverage for obesity/overweight indications is contingent on member benefit contract language allowing such coverage. Samples, coupons, promotions, or cash-pay prescriptions do not establish medical necessity. Continuation of therapy for patients established on therapy prior to current health plan membership requires: documentation that medication was covered by prior health plan, evidence of clinical benefit (disease stability), and confirmation that benefit contract allows coverage.

Policy effective March 15, 2026 · verified June 3, 2026 · source: dru787reg.pdf

What you need to qualify

• BMI of 27 or higher
• 6 months of a documented diet and exercise program
• Established cardiovascular disease (MI, stroke, and PAD)
• On guideline-directed medical therapy (blood_pressure_lowering_agents and cholesterol_lowering_agents)
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Clinical documentation (e.g., chart notes) confirming diagnosis of cardiovascular disease — at least one of: prior MI, prior stroke, or symptomatic PAD (intermittent claudication with ABI < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease)
• Documentation of BMI >= 27 kg/m2
• Attestation that patient does NOT have type 2 diabetes mellitus
• Attestation that patient will use optimized pharmacotherapy (blood pressure and cholesterol lowering agents) for established CVD in combination with requested agent
• Attestation that medication will be used with lifestyle modification
• For continuation: attestation that patient continues to use optimized pharmacotherapy for established CVD

Quantity limits

• all strengths - injection — 4 pens per 28 days
• all strengths - tablet — 30 tablets per 30 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Attestation that the patient will continue to use optimized pharmacotherapy (such as blood pressure and cholesterol lowering agents) for established cardiovascular disease in combination with the requested agent. T2DM exclusion and GDMT attestation requirement are re-verified at continuation.

Not covered when

• Type 2 diabetes mellitus (patients with T2DM were excluded from SELECT trial; Ozempic noted as lower-cost alternative for T2DM patients)
• NYHA class IV heart failure
• Primary prevention (no established CVD) — efficacy unknown
• Co-administration with other weight loss medications considered investigational
• Diabetic ketoacidosis (DKA)
• Type 1 diabetes

Policy note: Indication is MACE secondary prevention only. GDMT attestation is required at both initial and continuation (optimized pharmacotherapy such as blood pressure and cholesterol lowering agents). T2DM is excluded from this indication based on SELECT trial design; the document explicitly notes Ozempic as a lower-cost alternative for T2DM patients. Coverage for MACE prevention is NOT subject to weight loss benefit contract language restriction — it qualifies under standard coverage without the obesity benefit rider requirement. No ABI cutoff is stated in the policy for PAD beyond < 0.85 for intermittent claudication.

Policy effective July 15, 2026 · verified July 16, 2026 · source: dru787reg.pdf

What you need to qualify

• BMI of 27 or higher
• 6 months of a documented diet and exercise program
• Established cardiovascular disease (MI, stroke, and PAD)
• On guideline-directed medical therapy (blood_pressure_lowering_agents and cholesterol_lowering_agents)
• Not being used to treat type 1 diabetes

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Clinical documentation (such as chart notes) confirming established cardiovascular disease (prior MI, stroke, or symptomatic PAD)
• For symptomatic PAD: evidence of intermittent claudication with ABI < 0.85 at rest, peripheral arterial revascularization procedure, or amputation due to atherosclerotic disease
• Documentation of BMI >= 27 kg/m2
• Attestation that patient will use optimized pharmacotherapy (blood pressure and cholesterol lowering agents) for established CVD in combination with Wegovy
• Attestation that medication will be used with lifestyle modification

Quantity limits

• all strengths - injection — 4 pens/28 days
• all strengths - tablet — 30 tablets/30 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Attestation that the patient will continue to use optimized pharmacotherapy (such as blood pressure and cholesterol lowering agents) for established cardiovascular disease in combination with Wegovy. BMI, CVD diagnosis, and T2DM exclusion are not explicitly re-verified at continuation.

Not covered when

• Type 2 diabetes (T2DM) — patients with T2DM were excluded from the SELECT trial; policy notes Ozempic as a lower-cost option for T2DM patients needing MACE risk reduction
• NYHA class IV heart failure
• Co-administration with other medications for obesity or overweight (Contrave, Qsymia) is considered investigational
• Type 1 diabetes

Policy note: This indication is for secondary prevention of MACE only (not primary prevention). The policy notes that efficacy/safety for primary prevention is unknown. Standard of care for CVD (blood pressure lowering agents, cholesterol lowering agents) must be used in combination. The policy references AHA/ACC guidelines recommending antiplatelets/anticoagulants, beta blockers, and ACE inhibitors/ARBs for secondary prevention, and statins as first-line lipid therapy. Coverage for this indication does NOT appear to require the weight loss benefit rider, unlike the obesity/overweight indication.

Policy effective March 15, 2026 · verified June 3, 2026 · source: dru787reg.pdf

What you need to qualify

• 6 months of a documented diet and exercise program
• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by liver_biopsy, FibroScan_VCTE, ELF_test, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Clinical documentation (e.g., chart notes) confirming diagnosis of MASH established by or in consultation with a gastroenterologist or hepatologist
• Documentation of Stage F2 or F3 fibrosis confirmed by one of: liver biopsy, vibration-controlled transient elastography (VCTE), Enhanced Liver Fibrosis (ELF) score, or magnetic resonance elastography (MRE)
• Attestation that medication will be used with lifestyle modification
• For continuation: attestation of clinical benefit such as stability or improvement of liver fibrosis stage relative to baseline

Quantity limits

• all strengths - injection — 4 pens per 28 days
• all strengths - tablet — 30 tablets per 30 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Attestation that the medication is providing clinical benefit, such as stability or improvement of liver fibrosis stage relative to baseline.

Not covered when

• Cirrhotic MASH (policy specifies noncirrhotic only)
• Co-administration with other weight loss medications considered investigational
• Diabetic ketoacidosis (DKA)
• Type 1 diabetes

Policy note: MASH indication is NOT subject to the weight loss benefit contract language restriction — it qualifies under standard coverage without the obesity benefit rider requirement. Prior to 6/4/2026 revision, there was a requirement for prior failure to achieve weight loss goals with diet and exercise; this has been removed. Specialist (gastroenterologist or hepatologist) diagnosis or consultation is explicitly required. No lookback periods specified for confirmatory testing. Wegovy HD added at parity 6/4/2026. BMI >= 27 kg/m2 was observed in the ESSENCE trial population but is not listed as a policy coverage criterion.

Policy effective July 15, 2026 · verified July 16, 2026 · source: dru787reg.pdf

What you need to qualify

• Prescribed by or in consultation with a specialist
• Confirmed MASH diagnosis by liver_biopsy, FIB-4, FibroScan_VCTE, ELF_test, and MRE, fibrosis stage F2 to F3

Qualification pathways

You can qualify through any one of these.

Documentation to bring

• Clinical documentation (such as chart notes) of MASH/NASH diagnosis established by or in consultation with a gastroenterologist or hepatologist
• Documentation confirming noncirrhotic status
• Fibrosis staging confirmation: liver biopsy showing F2 or F3 fibrosis OR at least two of the following: FIB-4 score consistent with F2/F3 adjusted for age, VCTE result, ELF score, MRE result
• Attestation of failure to achieve weight-loss goals with diet and exercise

Quantity limits

• all strengths - injection — 4 pens/28 days
• all strengths - tablet — 30 tablets/30 days

Approval and renewal

• Initial approval: 12 months
• Renewal: every 12 months
• To renew, the plan looks for Attestation that the medication is providing clinical benefit, such as stability or improvement of liver fibrosis stage relative to baseline.

Not covered when

• Cirrhotic MASH (policy specifies noncirrhotic only)
• Co-administration with other medications for obesity or overweight (Contrave, Qsymia) is considered investigational

Policy note: MASH criteria were added to this policy effective 1/22/2026. The MASH indication does not appear to require the weight loss benefit rider. Fibrosis must be Stage F2 or F3 (not F1 or F4/cirrhotic). When biopsy is not used, at least TWO of the four non-biopsy tests must confirm F2/F3 fibrosis. The SELECT trial (BMI >=27 kg/m2) informs the MASH evidence base, but no explicit BMI threshold is stated in the MASH coverage criteria. Policy notes AASLD guidelines endorse weight-loss and comorbidity management for MASH.

Policy effective March 15, 2026 · verified June 3, 2026 · source: dru787reg.pdf