Getting Wegovy covered by insurance requires meeting specific medical criteria and navigating a process that varies widely depending on your plan type. The core qualifications are straightforward: a BMI of 30 or higher, or a BMI of 27 or higher with at least one weight-related health condition like high blood pressure, type 2 diabetes, or high cholesterol. But meeting those thresholds is only the first step. Most insurers layer on additional requirements before they’ll approve coverage.
The Medical Criteria You Need to Meet
Wegovy’s FDA-approved indications set the baseline that insurers use when evaluating coverage requests. For adults, there are two qualifying paths based on body weight:
- BMI of 30 or greater (obesity): No additional health conditions required.
- BMI of 27 to 29.9 (overweight): You must also have at least one weight-related condition. The most common qualifying conditions are high blood pressure, type 2 diabetes, and high cholesterol (dyslipidemia), though others may count depending on your insurer.
For adolescents aged 12 and older, the standard is a BMI at or above the 95th percentile for their age and sex, which corresponds to clinical obesity in pediatric terms.
There’s also a separate, newer indication that matters for Medicare patients specifically. Wegovy is approved to reduce the risk of major cardiovascular events (heart attack, stroke, or cardiovascular death) in adults who already have established heart disease and either obesity or overweight. In a large clinical trial of over 17,000 patients, Wegovy reduced the risk of these events by 20% compared to placebo. This cardiovascular indication opens a coverage door that didn’t exist before 2024.
Why Your BMI Alone Isn’t Enough
Even if you clearly meet the BMI criteria, most insurance plans require additional documentation before approving Wegovy. The most common extra requirements include proof that you’ve already tried other approaches to weight management, typically diet and exercise for a set period (often 3 to 12 months), and that these efforts haven’t been sufficient on their own.
Many plans also impose what’s called step therapy. This means you’ll need to try one or more cheaper weight loss medications first and show that they didn’t work, caused intolerable side effects, or were medically inappropriate for you. The medications insurers commonly require as first steps include phentermine (an older appetite suppressant), the combination of phentermine and topiramate, or Saxenda (an older, less effective injection in the same drug class as Wegovy). Only after documenting failure with these alternatives will some plans authorize Wegovy.
Your doctor’s office will typically handle the prior authorization paperwork, but it helps to know what the insurer is looking for so you can make sure your medical records reflect it. Documented weight history, a record of past weight loss attempts, and lab work showing qualifying conditions like elevated cholesterol or blood sugar all strengthen your case.
Coverage Rates Are Still Low
One of the biggest obstacles is simply whether your plan covers Wegovy at all. Among employer-sponsored health plans, only about 14.6% currently cover Wegovy. That means roughly 85% of people with workplace insurance don’t have access to coverage for this medication regardless of their medical qualifications. A survey by the benefits consulting firm WTW found that 70% of employers who don’t currently cover obesity medications said they’d consider adding coverage if costs came down, but for now, most plans exclude it.
Before going through the prior authorization process, call the number on the back of your insurance card or check your plan’s formulary (the list of covered drugs) online. If Wegovy isn’t on the formulary, you can still request a formulary exception, but approval rates for exceptions are generally lower than for drugs already on the covered list.
How Medicare Coverage Works
Medicare Part D has historically excluded coverage of any medication prescribed solely for weight loss. That changed partially in March 2024, when Wegovy gained FDA approval for cardiovascular risk reduction. Medicare Part D now covers Wegovy for enrollees who have both established cardiovascular disease and obesity or overweight. If you’re on Medicare and your doctor prescribes Wegovy purely for weight management without a cardiovascular diagnosis, Part D still won’t cover it under current rules.
The Centers for Medicare and Medicaid Services has proposed reinterpreting the statutory exclusion to allow broader Part D coverage of anti-obesity medications when used to treat obesity as a disease, not just for “weight loss.” If finalized, this would significantly expand access for Medicare beneficiaries, but as of now, the cardiovascular requirement remains in place.
Medicaid Coverage Varies by State
Medicaid coverage for Wegovy is limited. Only 13 state Medicaid programs cover GLP-1 medications for obesity treatment under their fee-for-service programs. Those states are Alaska, Arizona, Arkansas, Colorado, Florida, Georgia, Hawaii, Idaho, Illinois, Minnesota, North Carolina, Oregon, and Wisconsin. If you live outside these states and have Medicaid, coverage for Wegovy as a weight management drug is unlikely through your plan.
Even within states that do cover it, Medicaid managed care plans (which cover the majority of Medicaid enrollees) may have different formularies and requirements than the state’s fee-for-service program. Check with your specific plan rather than assuming statewide rules apply to you.
What to Do If You’re Denied
Insurance denials for Wegovy are common, but they’re not always final. You have the right to appeal, and the process works better when your appeal includes specific elements that reviewers look for.
A successful appeal typically demonstrates three things: that you meet the FDA-approved criteria (BMI thresholds and qualifying conditions), that you’ve tried and failed appropriate alternatives (or have a documented medical reason you can’t use them), and that Wegovy is consistent with generally accepted standards of medical practice for your situation. In one external appeal case reviewed by New York’s Department of Financial Services, the patient’s approval hinged on documentation of a 12-month trial of diet and exercise without success, plus evidence that all formulary alternatives had been tried or were contraindicated.
Ask your prescribing doctor to write a letter of medical necessity that specifically addresses your insurer’s stated reason for denial. If the denial says you haven’t tried step therapy, the letter should detail what you’ve tried and why it wasn’t effective. If the denial questions medical necessity, the letter should connect your weight-related health conditions to the clinical evidence supporting Wegovy. Keep the language tied to the insurer’s own criteria rather than making a general case for the medication.
Most plans offer two levels of internal appeal before you can request an independent external review. External reviews are decided by physicians who aren’t affiliated with your insurer, and they can overturn internal denials. The timelines vary by state and plan type, but you generally have 60 to 180 days from the denial date to file your first appeal.
Practical Steps to Improve Your Chances
Start by confirming Wegovy is on your plan’s formulary before your doctor submits a prior authorization. If it’s not listed, ask whether a formulary exception process exists. Some plans will grant exceptions when a doctor provides sufficient clinical justification.
Document everything in your medical record before the authorization request goes in. This means recent lab work showing qualifying conditions, notes from your doctor about past weight loss efforts, and records of any previous medications you’ve tried for weight management. The more complete your file is before the request, the less likely you are to face a denial based on missing information.
If your employer-sponsored plan doesn’t cover Wegovy, consider raising the issue during your company’s open enrollment feedback period. Employers make formulary decisions annually, and employee demand is one factor that influences whether obesity medications get added. Novo Nordisk, the maker of Wegovy, also offers a savings card program for commercially insured patients that can reduce out-of-pocket costs, though eligibility requirements and savings caps apply.