Regence · Weight Loss

Regence coverage for Wegovy (Weight Loss)

Employer / Commercial Insurance

Depends on your plan's benefit

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.

Adults with obesity

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age >= 18 years
BMI >= 30 kg/m2
Attestation medication will be used with lifestyle modification

Adults with overweight and comorbidity

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age >= 18 years
BMI >= 27 kg/m2
Attestation medication will be used with lifestyle modification

Plus any one of:

Hypertension
Dyslipidemia
Type 2 diabetes mellitus
Pre-diabetes
Insulin resistance
Obstructive sleep apnea
Cardiovascular disease
Symptomatic arthritis of lower extremities

Pediatrics (12-17 years) with obesity

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age 12 through 17 years
BMI >= 95th percentile standardized for age and sex
Attestation medication will be used with lifestyle modification

Continuation of therapy - established on therapy prior to current health plan membership

All of:

Patient was established on therapy prior to current health plan membership
Documentation that medication was covered by another health plan
Clinical benefit such as disease stability
Member benefit contract allows coverage of medications for weight loss in obesity/overweight

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

ACA Marketplace

Depends on your plan's benefit

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.

Adult obesity (>=18 years)

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age >= 18 years
BMI >= 30 kg/m2
Attestation that medication will be used with lifestyle modification (dietary/caloric restriction, exercise, weight management program, nutritional counseling, behavioral therapy)

Adult overweight with comorbidity (>=18 years)

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age >= 18 years
BMI >= 27 kg/m2
Attestation that medication will be used with lifestyle modification

Plus any one of:

Hypertension
Dyslipidemia
Type 2 diabetes mellitus (T2DM)
Pre-diabetes
Insulin resistance
Obstructive sleep apnea (OSA)
Cardiovascular disease (CVD)
Symptomatic arthritis of lower extremities

Pediatric obesity (12-17 years) - Wegovy

All of:

Member benefit contract allows coverage of medications for weight loss in obesity/overweight
Age 12 through 17 years
BMI >= 95th percentile standardized for age and sex
Attestation that medication will be used with lifestyle modification

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

All Wegovy policies under Regence · Check your card