Applies to Employer plans.
Depends on your plan's benefitCovered only for select plans with specific benefit language allowing coverage of drugs for weight loss management; drugs for weight loss management are a standard exclusion for most benefit plans
Qualification pathways
You can qualify through any one of these.
Adult (18+) - Continuation/Already on therapy
All of:
- Patient is 18 years of age or older
- Patient has completed at least 3 months of therapy with Wegovy at a stable maintenance dose
- Patient lost at least 5% of baseline body weight OR has continued to maintain their initial 5% weight loss (documentation required)
- Patient is currently on and will continue to be on a weight loss regimen of reduced calorie diet, increased physical activity, and behavioral modifications
- Patient will NOT be using the requested agent in combination with another targeted weight loss agent
- Patient does not have a diagnosis of type 2 diabetes mellitus as a comorbid weight-related condition
Adult (18+) - New to therapy with BMI ≥ 30
All of:
- Patient is 18 years of age or older
- Patient has participated in a comprehensive weight management program encouraging behavioral modification, reduced calorie diet and increased physical activity with continuing follow-up for at least 6 months prior to drug therapy
- Patient has a baseline BMI ≥ 30 kg/m2
- Patient is currently on and will continue to be on a weight loss regimen of reduced calorie diet, increased physical activity, and behavioral modifications
- Patient will NOT be using the requested agent in combination with another targeted weight loss agent
- Patient does not have a diagnosis of type 2 diabetes mellitus as a comorbid weight-related condition
Adult (18+) - New to therapy with BMI ≥ 27 and comorbidity (non-CVD)
All of:
- Patient is 18 years of age or older
- Patient has participated in a comprehensive weight management program encouraging behavioral modification, reduced calorie diet and increased physical activity with continuing follow-up for at least 6 months prior to drug therapy
- Patient has a baseline BMI ≥ 27 kg/m2
- Patient has at least one weight-related comorbid condition (e.g., hypertension or dyslipidemia)
- Patient is currently on and will continue to be on a weight loss regimen of reduced calorie diet, increased physical activity, and behavioral modifications
- Patient will NOT be using the requested agent in combination with another targeted weight loss agent
- Patient does not have a diagnosis of type 2 diabetes mellitus as a comorbid weight-related condition
Pediatric (12-17) - Continuation/Already on therapy
All of:
- Member is 12 to 17 years of age
- Member has completed at least 3 months of therapy with Wegovy at a stable maintenance dose
- Member has at least 5% reduction in BMI from baseline OR has continued to maintain their initial 5% reduction in BMI from baseline (documentation required)
- Member is currently on and will continue to be on a weight loss regimen of reduced calorie diet, increased physical activity, and behavioral modifications
- Member will NOT be using the requested agent in combination with another targeted weight loss agent
- Patient does not have a diagnosis of type 2 diabetes mellitus as a comorbid weight-related condition
Pediatric (12-17) - New to therapy
All of:
- Member is 12 to 17 years of age
- Member has participated in a comprehensive weight management program encouraging behavioral modification, reduced calorie diet and increased physical activity with continuing follow-up for at least 6 months prior to drug therapy
- Member has an initial BMI at the 95th percentile or greater standardized for age and sex
- Member is currently on and will continue to be on a weight loss regimen of reduced calorie diet, increased physical activity, and behavioral modifications
- Member will NOT be using the requested agent in combination with another targeted weight loss agent
- Patient does not have a diagnosis of type 2 diabetes mellitus as a comorbid weight-related condition
Documentation to bring
- Chart notes or medical record documentation of Body Mass Index (BMI)
- Chart notes or medical record documentation of weight-related comorbid condition, if applicable
- Documentation of at least 5% baseline body weight loss or maintained 5% weight loss (for adults on continuation)
- Documentation of at least 5% BMI reduction from baseline or maintained 5% BMI reduction (for pediatrics on continuation)
Quantity limits
- All strengths — 4 pens
Approval and renewal
- Initial approval: 6 months
- Renewal: every 12 months
- Renewal: At least 5% reduction in BMI.
- Renewal: For adults: lost at least 5% of baseline body weight OR maintained initial 5% weight loss after at least 3 months at stable maintenance dose. For pediatrics (12-17): at least 5% reduction in BMI from baseline OR maintained initial 5% BMI reduction after at least 3 months at stable maintenance dose.
- Renewal: At least 12 weeks on therapy before the first renewal.
Not covered when
- Type 2 diabetes mellitus as a comorbid weight-related condition (must resubmit for GLP-1 approved for T2DM)
- Combination use with another targeted weight loss agent
- Plans without specific benefit language allowing weight loss drug coverage
Policy note: Document covers Wegovy (semaglutide injection), Wegovy HD (semaglutide injection), and Wegovy (semaglutide tablet) under a single section V for adults, and section VI for pediatrics. The weight loss criteria and approval durations are the same across all three formulations for the adult indication. Wegovy HD and Wegovy tablet do not have a listed pediatric indication in this policy. Members receiving medication via samples or manufacturer patient assistance programs must meet initial approval criteria. Approvals may be subject to dosing limits per FDA labeling.
Policy effective May 19, 2026 · verified June 3, 2026 · source: Drugs For Weight Loss Management · View policy document (PDF)