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.

Active Ingredient: Semaglutide

Semaglutide is a GLP-1 receptor agonist only. It mimics the hormone GLP-1, which helps regulate blood sugar and appetite. In the United States, Semaglutide is available as: Ozempic, Wegovy, and Rybelsus.

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?

In most cases, insurance won’t cover Wegovy, but the full answer is more complex. Coverage depends on the insurance provider, the specific plan, the diagnosis, and the patient’s medical history. Even though the FDA approved Wegovy for weight loss, that approval doesn’t guarantee coverage.

To determine if your plan covers Wegovy, review your insurance policy in detail. Many insurers set strict criteria, such as requiring a documented history of obesity, a qualifying diagnosis, or proof of previous weight management attempts. Insurers often require prior authorization and may request medical records, BMI documentation, and details about related health conditions. If an insurer denies initial coverage, you can file an appeal or work with your healthcare provider to demonstrate medical necessity and submit supporting documentation.

You can also explore weight management programs offered by your insurer, since some plans include coverage for related treatments or services. Because coverage terms vary so widely, you need to contact your insurance provider directly and review your policy documents carefully.

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, first review your current plan thoroughly. Your insurance provider lists all covered medications in a formulary, which you can access through the provider’s website or app.

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. Some insurers require prior authorization before they approve Wegovy coverage:

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: Collect medical records that support the need for Wegovy, including weight, BMI, relevant comorbidities (such as diabetes, hypertension, or heart disease), and past 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 insurers use to manage costs and encourage effective treatments. When an insurer requires step therapy for Wegovy, they usually approve coverage only after you first try less expensive or more established medications. If the initial treatment works, the insurer may deny the higher-cost option.

1. First-line Medication: Your healthcare provider prescribes a first-tier medication or treatment outlined in the insurance plan’s step therapy protocol. This step satisfies the insurer’s requirements.

2. Monitoring and Documentation: Your healthcare provider monitors progress on the initial medication and keeps detailed records of outcomes such as weight loss results, side effects, or other health concerns.

3. Meeting Step Therapy Requirements: If the first medication doesn’t work or causes problems, your provider documents these issues and submits the information to the insurer. This documentation may allow you to move to the next tier of treatment options, which could include Wegovy.

4. Wegovy Insurance Approval: Once you meet step therapy requirements, your insurer reviews your case and decides whether to approve coverage for Wegovy.

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

1. FDA Label: OZEMPIC (Semaglutide Injection) Medication Guide
2. FDA Label: WEGOVY (Semaglutide Injection) Medication Guide
3. FDA Label: RYBELSUS (Oral Semaglutide) Medication Guide