Is Wegovy Covered By Insurance? And What to Do If Your Wegovy Prescription Isn’t Covered

Wegovy, an FDA-approved GLP-1 receptor agonist, has become increasingly recognized for its role in weight management. However, the high cost of this prescription medication can present a significant barrier for many individuals. Is Wegovy covered by insurance? Navigating insurance coverage options may help make Wegovy more affordable and accessible for some people considering long-term weight management. This article provides general information about potential strategies for seeking insurance coverage for Wegovy, which may help reduce out-of-pocket costs for eligible individuals. As always, consult a qualified healthcare provider for personalized medical advice. Individual results and coverage eligibility may vary. This content is for informational purposes only and does not constitute medical or insurance advice.

What does Wegovy cost without insurance

The price of weight loss medications like Wegovy can be prohibitively expensive, especially without insurance coverage. For those paying out-of-pocket, the costs can soar to over $1,000 per month, leaving many financially unable to access the medication.

Currently, the list price for a 30-day supply of Wegovy stands at a steep $1,349.

The cost of Wegovy without insurance can vary depending on the pharmacy and your location. However, without discounts or assistance programs, individuals may expect to pay a significant amount out-of-pocket each month.

Eligible individuals can apply for Novo Nordisk’s Patient Assistance Program, but the criteria for this program is strict and not many will qualify.

What does Wegovy cost with insurance?

When an insurance plan covers Wegovy, monthly out-of-pocket costs may be reduced. The Wegovy pricing tool can provide an estimate of costs with insurance based on the specific plan.

Even when Wegovy is not explicitly covered, some insurance plans may still offer ways to help lower expenses. Individuals with commercial (private) insurance who are not enrolled in government-funded programs may qualify for the Wegovy Copay Card, which can offer additional savings.

Eligibility requirements and savings amounts vary, so it is important to review the terms and check with the insurance provider for details.

Will insurance cover Wegovy?

Generally, the answer is no. But the full answer is more complex. Coverage for Wegovy varies widely depending on insurance providers, individual plans, diagnosis, and medical history. While Wegovy is FDA-approved for weight loss, that doesn’t guarantee insurance coverage.

Determining whether a Wegovy prescription is covered requires a detailed review of the specific insurance policy. Many plans have particular criteria that must be met, such as a documented history of obesity, a qualifying diagnosis, or evidence of previous weight management attempts. Prior authorization is often required, and insurers may request medical records, BMI documentation, and information about related health conditions. In cases where initial coverage is denied, it may be necessary to file an appeal or work with a healthcare provider to demonstrate medical necessity and provide supporting documentation.

Exploring any weight management programs offered by the insurer can also be beneficial, as some plans provide coverage for related treatments or services. Coverage terms and requirements vary widely, so contacting the insurance provider directly and reviewing policy documents is essential.

Why is Wegovy prescription not covered by insurance?

Obesity is now widely recognized as a chronic condition, one that can be effectively treated with medications like Wegovy. Given the number of comorbidities associated with obesity—such as heart disease, diabetes, and hypertension—it seems logical that insurance companies would cover weight loss treatments to reduce their own long-term financial risk.

After all, helping people manage their weight could potentially prevent costly medical complications down the line. So, why don’t they?

The truth is, because they don’t have to.

Despite the clear health benefits, weight loss treatments often fall outside the mandatory coverage guidelines. In the U.S., insurance companies are not obligated to cover weight loss medications under the Affordable Care Act. They are only required to provide obesity screening and counseling services.

How to get Wegovy covered by insurance?

If you’re trying to get Wegovy insurance coverage, the first step is thoroughly reviewing your current plan. Your insurance provider should have a formulary listing all the medications covered. This information can typically be found through your insurance app or the provider’s website.

The formulary listing should include information like coverage tiers, copays, and any special requirements. Some insurance providers require specific authorizations before granting Wegovy insurance approval.

If your insurance requires Prior Authorization:

For individuals seeking Wegovy insurance coverage, reviewing the current insurance plan details is typically the starting point. Insurance providers generally maintain a formulary listing covered medications, accessible via their website or mobile app.

Formularies typically outline coverage tiers, copayment amounts, and special requirements. Prior authorization may be required by some insurers before Wegovy coverage is approved:

1. Understand Coverage Criteria: Coverage criteria for weight loss medications often include specific requirements set by insurance providers, such as meeting a certain BMI threshold or providing documentation of obesity-related health conditions.
2. Gather Medical Documentation: Medical documentation supporting the necessity of Wegovy may be required, including details such as weight, BMI, relevant comorbidities (for example, diabetes, hypertension, or heart disease), and records of previous weight loss efforts or treatments.
3. Submit the Prior Authorization Request: After assembling the necessary documentation, a healthcare provider typically submits a prior authorization request to the insurance company, outlining the medical justification for Wegovy coverage.
4. Follow Up and Appeal if Necessary: If a prior authorization request is denied, an appeal process may be available. Additional documentation or clarification from the healthcare provider can sometimes help demonstrate medical necessity for Wegovy coverage.

If your insurance requires Step Therapy:

Step therapy is a standard process used by insurance companies to manage costs and promote the use of effective treatments. When step therapy is required for Wegovy, coverage approval typically depends on first trying less expensive or more established medications. If the initial treatment is effective, insurers may not approve the higher-cost option.

1. First-line Medication: A healthcare provider generally prescribes a first-tier medication or treatment, as specified by the insurance plan’s step therapy protocol. This step is intended to meet the insurer’s requirements.

2. Monitoring and Documentation: Progress on the initial medication is monitored, with detailed records kept regarding outcomes such as weight loss results, side effects, or other health concerns.

3. Meeting Step Therapy Requirements: If the first medication is not effective or is poorly tolerated, the healthcare provider documents these issues and submits the information to the insurer. This may allow progression to the next tier of treatment options, which could include Wegovy.

4. Wegovy Insurance Approval: After fulfilling step therapy requirements, coverage for Wegovy may be considered, depending on the insurance provider’s policies and approval process.

What insurance covers Wegovy?

There is no definitive list of insurance providers that cover Wegovy, and coverage can vary widely depending on the insurer, the specific plan, and individual eligibility criteria. Research and direct confirmation with insurance providers are necessary to determine if Wegovy is included in a particular plan.

To identify coverage options, you may need to:

1. Research Insurance Providers: Compile a list of insurance companies that address existing medical needs, then identify plans that align with specific requirements.

2. Review Plan Details: Examine each plan’s coverage information, focusing on whether weight loss medications, including Wegovy, are included.

3. Confirm Coverage: Contact the insurance provider directly to verify if Wegovy is covered under the plan and to clarify any requirements or restrictions.

4. Switch Plans: After selecting the plan that best fits all needs, complete the enrollment process and confirm when coverage becomes active.

Alternatives to Wegovy covered by insurance

If your current insurance plan does not cover your Wegovy prescription—or you aren’t able to find a plan that meets all your needs—it may be time to consider alternatives to Wegovy that are covered by insurance.

You have options like:

• Ozempic
• Zepbound
• Mounjaro
• and more.

Unfortunately, they are impacted by the same issue as Wegovy: insurance providers are not required to provide coverage for weight loss medications. So, you’ll need to check your insurance plan’s formulary to see which medications may be covered.

Get your Wegovy prescription online

After confirming insurance coverage, the next step typically involves contacting a healthcare provider to begin the process of obtaining a Wegovy prescription. The provider can assist with any necessary procedures, such as prior authorization or step therapy, to help facilitate access to treatment.

For those interested in starting Wegovy without in-person appointments, registration with Heally offers an alternative. Heally’s platform allows for online consultations with licensed healthcare providers, making it possible to receive a Wegovy prescription quickly and conveniently from home.

Register today and explore your options.

Sources

• Novo Nordisk: Wegovy Pricing
• Healthinsurance.org: Does health insurance cover drugs used for weight loss such as Ozempic, Wegovy, Mounjaro, and Zepbound?
• Aetna: Specialty Pharmacy Clinical Policy Bulletins, Subject: Wegovy PA Policy 4774-A 08-2022 v2
• Honest Care: Prior Authorization for Wegovy: criteria, process and denials