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

Wegovy, a GLP-1 receptor agonist, has gained popularity for its effectiveness in supporting weight loss—and it’s FDA_approval for weight management. Unfortunately, the high cost of this prescription can be a significant barrier for many.

Navigating insurance coverage options is key to making Wegovy more affordable and accessible as a long-term weight management solution. In this article, we discuss how to get Wegovy covered by insurance so you can reduce the financial burden of this weight loss medication.

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 actual cost of Wegovy without insurance may vary based on your pharmacy of choice and your location. But, without discounts, you will be paying at least that much per 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?

You can significantly lower your monthly out-of-pocket costs if your insurance plan will cover your Wegovy prescription. You can use the Wegovy pricing tool to see the cost of Wegovy with insurance based on your current plan.

Even if your insurance plan doesn’t exclusively cover Wegovy, there are ways insurance can help you save.

If you’re enrolled in a commercial (or private) insurance plan and are not enrolled in any government, state, or federally funded medical or prescription benefit programs, you may be eligible for the Wegovy Copay Card.

Will insurance cover Wegovy?

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

To find out if a Wegovy prescription is covered by your plan, you’ll need to review your insurance policy in detail. Some plans may have specific criteria, such as a documented history of obesity or a particular diagnosis, that you must meet to qualify for coverage. In some cases, you might need to appeal a denial or work with your healthcare provider to demonstrate medical necessity.

It’s also worth looking into any weight management programs your insurer might offer, as they may provide some coverage for related treatments.

Why is my 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:

Prior authorization is a process where your insurance company requires approval before agreeing to cover a specific medication like Wegovy. It ensures the treatment is medically necessary based on your health history and diagnosis.

You will need to work closely with your healthcare provider to submit a claim. Here’s how you can collaborate with your healthcare provider to navigate this hurdle:

Understand Coverage Criteria: Many insurance companies have specific criteria for covering weight loss medications. Ensure you and your healthcare provider are aware of these requirements. For instance, your insurance may require that you meet a certain BMI threshold or have documented evidence of obesity-related conditions.
Gather Medical Documentation: Your doctor will need to provide detailed documentation supporting why Wegovy is medically necessary for you. This may include your weight, BMI, any comorbidities (such as diabetes, hypertension, or heart disease), and previous weight loss attempts. If you’ve tried other weight loss medications or interventions without success, this information can help to strengthen your claim.
Submit the Prior Authorization Request: Once all the necessary documentation is in order, your healthcare provider will submit the prior authorization request to your insurance company. This request essentially asks for approval to cover Wegovy based on your unique medical needs.
Follow Up and Appeal if Necessary: After submission, stay in touch with your insurance company to check on the status of your claim. If it’s denied, don’t lose hope—you can appeal the decision. Your healthcare provider may need to provide additional documentation or clarification to demonstrate why Wegovy is the best option for you.

If your insurance requires Step Therapy:

Step therapy is a common requirement by insurance companies designed to control costs while ensuring patients receive effective treatments. If your insurance mandates step therapy for Wegovy, it means that before approving coverage for this medication, they require you to try less expensive or more established treatments first. The idea is that if the first treatment proves effective, there’s no need for the more expensive option.

Here’s how step therapy works and what to expect:

First-line Medication: Your doctor will prescribe the first-tier medication or treatment that your insurance requires you to try. This step is necessary to satisfy the insurance company’s criteria.
Monitoring and Documentation: Throughout this process, you’ll need to work closely with your healthcare provider to monitor your progress on the initial medication. Keep detailed records of your results, such as any lack of progress in weight loss, unwanted side effects, or other health concerns.
Meeting Step Therapy Requirements: If the first medication is ineffective or not well-tolerated, your healthcare provider will document the issues and submit this information to your insurance company. They may move you to the next tier of treatment options—which may or may not be a Wegovy prescription.
Wegovy Insurance Approval: Once you’ve met the step therapy requirements, you can move on to Wegovy, assuming it’s approved.

What insurance covers Wegovy?

If you’re shopping for insurance or looking to switch to a plan that includes Wegovy insurance coverage, it’s going to require a bit of legwork on your part. Unfortunately, there’s no clear cut list of insurance providers that have Wegovy insurance coverage or ways to gain Wegovy insurance approval.

Follow these steps to find the right coverage to suit all your needs:

Research Insurance Providers: Start by making a list of insurance providers that cover all of your other medical needs. Then find the plans that best suit your unique requirements.
Review Plan Details: Next, you’ll want to examine the coverage specifics for each plan. Focus on policies that include weight loss medications, specifically Wegovy.
Confirm Coverage. You don’t want to make such a big decision without being sure. Reach out to the insurance provider to verify whether or not they actually offer Wegovy insurance coverage.
Switch Plans. Once you’ve identified the plan that best meets all your needs, complete the enrollment process. Make sure to follow all the necessary steps and understand when coverage will begin.

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:

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

Once you’ve figured out your insurance coverage, the next step is to reach out to your healthcare provider to begin the process of obtaining your Wegovy prescription. Your doctor will guide you through any necessary steps, including prior authorization or step therapy, ensuring you’re on track for treatment.

If you’re ready to start your weight loss journey with Wegovy, you can skip the hassle of in-person visits by registering with Heally. Through Heally’s platform, you can consult with a licensed healthcare provider online and get your Wegovy prescription quickly and conveniently, all from the comfort of your home.