Getting Wegovy covered by insurance requires meeting specific medical criteria, navigating prior authorization, and sometimes appealing a denial. The process varies significantly depending on whether you have commercial insurance, Medicare, or Medicaid, but the core steps are the same: confirm your plan covers the drug, document that you qualify, and submit the right paperwork.
Check Whether Your Plan Covers Wegovy at All
Before anything else, find out if your health plan includes Wegovy on its formulary (the list of covered drugs). Many employer-sponsored plans exclude weight loss medications entirely, and they have broad legal discretion to do so. High utilization and rising costs have led some employers to drop coverage even after initially offering it. Look at your Summary of Benefits and Coverage or call the number on your insurance card and ask specifically whether anti-obesity medications are covered. Some plans cover these drugs only for diabetes, not for weight management alone, so pay attention to the exact indication.
If your plan excludes Wegovy, your options are limited to manufacturer savings programs (covered below), paying out of pocket, or asking your employer’s HR department whether coverage could be added during the next plan year. For self-insured employer plans, coverage decisions are made internally, so employee demand can sometimes influence what gets included.
The Medical Criteria You Need to Meet
Wegovy is FDA-approved for adults with a BMI of 30 or higher, or a BMI of 27 or higher combined with at least one weight-related condition such as high blood pressure, type 2 diabetes, or high cholesterol. It’s also approved for adolescents aged 12 and older with obesity. These are the baseline medical thresholds, and most insurers mirror them closely.
However, insurers typically add a requirement the FDA does not: documented participation in a structured weight management program. One representative set of criteria, used by CVS Caremark for the North Carolina State Health Plan, requires at least six months in a comprehensive program that includes behavioral modification, a reduced-calorie diet, and increased physical activity with ongoing follow-up. If you haven’t done this yet, ask your doctor to document your diet and exercise efforts in your medical record starting now. Gym memberships, dietitian visits, and participation in programs like WW or the CDC’s Diabetes Prevention Program all count as evidence.
How Prior Authorization Works
Almost every insurer requires prior authorization for Wegovy. This means your doctor’s office submits a request proving you meet the plan’s criteria before the pharmacy will fill the prescription. Your role is to make sure your doctor has everything needed to build a strong case.
Gather and bring the following to your appointment:
- BMI documentation: Your current height and weight, recorded at a clinical visit.
- Comorbidity records: If your BMI is between 27 and 29.9, you need documentation of a related condition. Lab results, blood pressure readings, or an existing diagnosis of type 2 diabetes or sleep apnea all work.
- Weight management history: Records showing you’ve attempted diet and exercise under professional guidance. Six months of documented effort is a common threshold, though some plans require less.
Your doctor’s office handles the actual submission. The turnaround is typically a few days to two weeks. If it’s approved, you’ll get an authorization number and can fill the prescription. If denied, you’ll receive a written explanation of why.
Keeping Coverage After You Start
Getting the first approval isn’t the end. Many insurers require reauthorization after the initial period, and they set specific benchmarks you need to hit. A common renewal standard requires that after three months at the full maintenance dose, you must have lost at least 5% of your baseline body weight. If you’ve already hit that target, you need to show you’ve maintained the loss. Documentation from your doctor is required at each renewal.
This means consistent weigh-ins at your provider’s office matter. If you skip appointments or your records are incomplete, your renewal can be denied even if you’re responding well to the medication. Keep a regular schedule of visits, and make sure your weight is recorded in your chart each time.
Medicare and Medicaid Coverage
Medicare Part D does not cover Wegovy when prescribed solely for weight loss. This is a longstanding exclusion. However, a path opened in March 2024 when Wegovy gained a second FDA approval: reducing the risk of heart attack, stroke, and cardiovascular death in patients who have obesity or overweight combined with established cardiovascular disease. Medicare Part D now covers Wegovy for that specific combination. If you have both a qualifying BMI and a history of heart disease, your doctor can prescribe it under the cardiovascular indication.
Medicare also covers other drugs in the same class when prescribed for type 2 diabetes, since that’s a separate approved use that falls outside the weight loss exclusion.
Medicaid coverage varies dramatically by state. Federal law allows states to exclude weight loss drugs from their Medicaid formularies, and most do. As of January 2026, only 13 state Medicaid programs cover GLP-1 drugs for obesity treatment under fee-for-service. Coverage for diabetes and cardiovascular indications is required in all states. One important exception: for children and adolescents, Medicaid’s Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit requires coverage if the medication is deemed medically necessary, regardless of the state’s general policy on weight loss drugs.
What to Do if You’re Denied
A denial is not the final answer. You have the right to appeal, and the process is worth pursuing, especially if the denial was based on incomplete information.
Start by requesting the denial reason in writing. The three most common reasons are “not medically necessary,” “experimental,” and “excluded benefit.” Each requires a different response. For a medical necessity denial, ask your doctor to write a letter detailing your specific health conditions, how obesity contributes to them, and why Wegovy is appropriate for your case. For an exclusion-based denial, make sure every relevant comorbidity has been reported. Conditions like sleep apnea, joint disease, or fatty liver disease sometimes go unmentioned in the initial submission but can strengthen an appeal.
Also check that the correct billing and diagnosis codes were used. Coding errors are a surprisingly common reason for denials, and fixing them can resolve the issue without a formal appeal. If your first-level appeal fails, most plans offer a second level, and you can request an external review by an independent third party. The Obesity Action Coalition offers template appeal letters and step-by-step guidance on their website.
Manufacturer Savings Programs
Novo Nordisk, the maker of Wegovy, runs two savings programs depending on your insurance situation.
If you have commercial insurance that covers Wegovy, you can use the savings card to pay as little as $25 per month for a 28-day supply of injections or a 30-day supply of the oral version. You need a valid prescription and cannot be enrolled in any government insurance program (Medicare, Medicaid, Tricare, or VA benefits).
If you don’t have insurance coverage for Wegovy, a separate program offers the injectable version at $199 per month for the first two months at starting doses, then $349 per month after that. The oral pill version is available at $149 per month for the lower doses. These programs have expiration dates and terms that change periodically, so check the Wegovy website or call Novo Nordisk’s support line for current pricing.
Neither program applies to government-insured patients. If you’re on Medicare and don’t qualify under the cardiovascular indication, these savings cards won’t help, and out-of-pocket costs remain the only alternative until coverage policies change.