How to get Wegovy covered by insurance (2024)

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We have finally entered an age where physicians, public health advocates, and insurers recognize that obesity is a disease that requires medical treatment. According to the Centers for Disease Control and Prevention, between 2017 and March 2020, 41.9% of Americans had obesity. What’s more, medical costs for adults with obesity were $1,861 higher than for people with a healthy weight. Obesity is a serious health issue associated with many leading causes of death, including heart disease, stroke, diabetes, and certain types of cancer.

“Obesity is truly a disease that is associated with many health conditions such as diabetes, heart disease, high blood pressure, and sleep apnea,” says Michelle Pearlman, MD, CEO and co-founder of Prime Institute and ByteMD, who is board certified in internal medicine, gastroenterology, and obesity medicine. “Most people are not able to lose weight with diet and exercise alone, and we need to treat the underlying metabolic issues. “

Wegovy is an injectible weight loss medication approved by the U.S. Food and Drug Administration (FDA). But is it possible to get Wegovy covered by insurance? The short answer is “sometimes.”

When insurance might cover Wegovy

Several insurance companies, including Blue Cross Blue Shield, Aetna, Cigna, and United Healthcare, cover Wegovy in some form or another. However, major insurance companies tend to offer several different types of plans, whether employer-sponsored or individually obtained. Coverage can vary greatly between plans, even if they’re offered by the same insurance company, so it is important to verify coverage before starting Wegovy. This is especially important because the drug’s high cost has some employers ending or limiting coverage of weight loss medications, including Wegovy.

Even if your insurance plan covers Wegovy, you need to meet its eligibility requirements. Insurance plans that cover Wegovy require that patients meet the following criteria:

  • Adults must have an initial body mass index (BMI) of 30 or higher; or
  • An initial BMI of 27 or higher (overweight) with at least one weight-related health condition, such as:
    • Heart disease
    • High cholesterol
    • Type 2 diabetes
    • High blood pressure
    • Sleep apnea
  • Pediatric patients ages 12 years and older must have an initial BMI at the 95th percentile or higher for age and sex.

How to get Wegovy covered by insurance

Getting Wegovy covered by insurance starts with a visit to your healthcare provider, who will determine whether you qualify for Wegovy. If you do, they’ll write you a prescription. You can either have your healthcare provider send the prescription to the pharmacy or rake it there yourself, where your pharmacist can check your coverage.

Alternatively, you can call your insurance company (the phone number is listed on the back of most insurance cards and prescription drug cards) to find out if your plan covers the cost of Wegovy before having the prescription sent to your pharmacy. You may want to also ask whether you need prior authorization. If so, your healthcare provider will have to contact your insurance company for approval before your prescription can be filled. If you are turned down, ask what you need to do to appeal.

“People need to be more well-informed,” Dr. Pearlman says. If you are turned down, ask why. “Did you not meet the criteria, or has your employer opted out of weight loss benefits?” If so, your healthcare provider can submit a request to the employer asking them to reconsider benefits or send an appeal to the insurance company to show that you meet the FDA requirements for the medication. “If you are having trouble getting medication covered, find a provider with experience with these medications who will be an advocate,” Dr. Perlman says.

What insurance covers Wegovy?

Most major insurance plans cover Wegovy, including Blue Cross Blue Shield, Aetna, Cigna, and United Health Care, but coverage may vary with each plan. Benefits offered by employer plans also vary, and coverage is often based on what employers are willing to cover.

Novo Nordisk, the manufacturer of Wegovy, sponsors NovoCare, a website with resources that help people check insurance coverage, manage the cost of medication, and more.

Does Medicare cover Wegovy?

Medicare does not cover weight loss medications and does not let people use manufacturer’s coupons in combination with their Part D plan. The ban on coverage for weight-loss treatments was instituted in 2003, partly due to concerns over the safety of fen-phen (the combination of fenfluramine and phentermine), the popular weight loss medication at the time. Fen-phen was associated with life-threatening hypertension and heart valve issues.

In July 2023, a bipartisan group in Congress reintroduced the Treat and Reduce Obesity Act (TROA), which would work to prevent diseases associated with obesity, including heart disease, stroke, Type 2 diabetes, and certain cancers that are leading causes of preventable death. The expansion of Medicare coverage for weight-loss medications would increase their availability for many older adults who cannot afford them and have a “multiplier effect” because private insurers often follow Medicare’s lead. This is only introduced legislation and is not yet a law.

Does Medicaid cover Wegovy?

Every state decides what prescription drugs to cover through Medicaid, so coverage for Wegovy depends on where you live. As of July 2023, nine states—California, Connecticut, Delaware, Michigan, Minnesota, Pennsylvania, Rhode Island, Virginia, and Wisconsin—have added Wegovy to Medicaid preferred drug lists that allow patients to receive coverage without undergoing “step therapy,” where they are required to try less expensive drugs first.

Does the VA cover Wegovy?

The Veterans Administration (VA) covers obesity management for eligible veterans, but whether it will cover the cost of Wegovy varies. Wegovy is not on the VA national formulary and requires a nonformulary drug request and prior approval. See your local VA office to discuss your options.

Wegovy cost with insurance

The cost of Wegovy with insurance depends on many factors, including the specifics of the plan, drug copays, and limits on coverage. In November 2023, Novo Nordisk told Reuters that 80% of insured patients pay less than $25 a month for Wegovy.

Wegovy cost without insurance

The typical cash price of a one-month supply of Wegovy is $1,803.46, but that cost varies by pharmacy. Although it’s expensive, there are ways to save on Wegovy. With a SingleCare prescription discount card, you’ll pay an average of $1,234 for a month’s supply of Wegovy, depending on your preferred pharmacy. If insurance does not cover Wegovy, or if you pay cash for your prescriptions, you may be able to use a NovoCare manufacturer’s coupon for up to $500 in savings for a 28-day supply.

A new indication—possible changes in coverage?

On March 8, 2024, the FDA approved a new indication for Wegovy. This indication is to lower the risk of heart-related death, heart attack, and stroke in adults with heart disease and obesity and in adults with heart disease who are overweight. This new approval makes Wegovy the first weight-loss medicine that is also FDA approved to prevent heart events. This new indication may help prompt insurance companies to provide better coverage of Wegovy, but information on insurance coverage for this indication is not yet available.

Bottom line

Many insurance plans cover Wegovy for patients who fit the criteria once someone has met their deductible, but this can vary by policy. Although weight loss medication can help, it’s not a quick fix for obesity.

“When we speak about obesity, we’re looking at a multi-disciplinary approach that includes behavioral interventions, lifestyle modifications, and pharmacology, “ says Raj Dasgupta, MD, a board-certified physician and associate professor of clinical medicine at the University of Southern California in Los Angeles. “It is especially important to realize that even when you are on medications, you need to continue with lifestyle modifications that include diet and exercise because when people stop these medications, they gain the weight back.”

How to get Wegovy covered by insurance (2024)

FAQs

What are the criteria for Wegovy to be covered by insurance? ›

If your insurance plan covers Wegovy, you'll usually need to meet the plan's coverage rules and weight requirements before it will pay for your prescription. BMI requirement: The FDA has approved Wegovy for those who have a body mass index (BMI) of 30 or higher.

How do you get Wegovy for $25 a month? ›

Start your patients on Wegovy® today for as little as $0

After the patient's thirteenth (13th) 28-day fill, patients may then pay as little as $25 per 28-day supply (1 box) of Wegovy®. Patients with commercial insurance who do not have coverage for Wegovy® can save $500 per 28-day supply (1 box).

What are the prior authorization requirements for Wegovy? ›

What is 'prior authorization' for Wegovy (Semaglutide) insurance coverage
  • Proof that the medication is working (patient lost at least 5% of their body weight within the first 3 months of taking Wegovy)
  • Proof that the patient has – and follows – a lifestyle & diet plan in addition to taking Wegovy.

How to get Wegovy paid for? ›

Prior authorizations (PAs) are required by some prescription insurance plans to cover certain medications. Your health care provider will need to submit a form to your insurance company to seek approval for Wegovy®. You can reach out to your health care provider's office and request that they initiate a PA.

Why would Wegovy be denied? ›

Some employers and other health plans are still reluctant to cover Wegovy due to its hefty $1,350 monthly price tag, which they say could significantly strain their budgets. They also have other questions, such as how long patients actually stay on the treatment.

What is the qualifying BMI for semaglutide? ›

To qualify for a medical weight loss program that includes weekly Semaglutide injections, you need to be considered obese, which means that you have a BMI of 30 or higher, or be considered overweight (a BMI of 27 or higher) with at least one weight-related health condition.

How do I pay $0 on Wegovy? ›

Request your Wegovy® Savings Offer and WeGoTogether® support

If you have private or commercial insurance with coverage, you may pay as little as $0 per 28-day supply (1 box) of Wegovy® subject to a maximum savings of $225 per 28-day supply (1 box) for up to 13 fills.

How to get Wegovy at a lower cost? ›

Once you have a prescription, you can get Wegovy for free or at a discount in one of the following ways.
  1. Novo Nordisk's Wegovy Savings Card program. ...
  2. Prescription discount cards. ...
  3. Insurance coverage options for Wegovy. ...
  4. 90-day or mail-order refills. ...
  5. HSAs and FSAs. ...
  6. Government insurance programs for accessing Wegovy for free.
Jan 12, 2024

How much does a 28-day supply of Wegovy cost? ›

Novo Nordisk (the manufacturer who makes Wegovy) lists the price of Wegovy at $1,349.02 for a 28-day supply. This list price reflects the out-of-pocket cost of Wegovy without health insurance. Wegovy is an injectable medication for weight management. Patients use prefilled injection pens once a week.

What does Wegovy cost with insurance? ›

How much does Wegovy cost with insurance? According to Novo Nordisk, the drug's manufacturer, 80% of insured patients pay less than $25 a month for Wegovy. But, Wegovy insurance coverage largely depends on a person's specific insurance policy. Some health insurance plans do not cover medications to treat obesity.

Why does Zepbound work better than wegovy? ›

Similar to Wegovy, Zepbound has these effects by acting like GLP-1. But it also acts like a second gut hormone called glucose-dependent insulinotropic polypeptide (GIP). Because of this, Zepbound is considered a dual GIP/GLP-1 agonist. GIP is thought to work together with GLP-1 for additive effects.

How do you get approved for semaglutide? ›

The FDA recommends Wegovy for weight loss if you meet one of the following criteria:
  1. Have a body mass index (BMI) of 27kg/m2 or greater and at least one weight-related condition, such as high blood pressure, Type 2 diabetes or high cholesterol.
  2. Have a BMI of 30kg/m2 or greater.

How to get Wegovy if insurance won't cover it? ›

If your employer-provided insurance plan doesn't cover Wegovy®, you can ask your health care provider to write a letter to your human resources department.

How do I get semaglutide for $25 a month? ›

If you have private or commercial insurance, such as insurance you receive through an employer, you may be eligible to pay as little as $25 for a 1-, 2-, or 3-month prescription (maximum savings of $150 per 1-month prescription, $300 per 2-month prescription, or $450 per 3-month prescription).

What is the average out of pocket cost for Wegovy? ›

A package of Wegovy contains four pens, each pre-filled with a single dose of Wegovy. Without insurance, the list price of Wegovy is $1,349.02 per package, which breaks down to $269.80 per week or $16,188.24 per year. Even without health insurance, it is possible to save on Wegovy and bring down the cost of Wegovy.

What diagnosis is Wegovy approved for? ›

“Wegovy is now the first weight loss medication to also be approved to help prevent life-threatening cardiovascular events in adults with cardiovascular disease and either obesity or overweight,” said John Sharretts, M.D., director of the Division of Diabetes, Lipid Disorders, and Obesity in the FDA's Center for Drug ...

How easy is it to get a prescription for Wegovy? ›

The best way to get a prescription for Wegovy is by making an appointment with your doctor or nurse practitioner. During your visit, your healthcare professional will likely review your medical history, perform a physical exam, and discuss your current lifestyle to determine whether Wegovy is right for you.

How to get Wegovy when not covered by insurance? ›

If you do not have insurance, contact Novo Nordisk, the manufacturer, 1-888-809-3942 (Monday-Friday, 8:00 am-8:00 pm ET) to determine if you qualify for a Wegovy Savings Copay Card or patient financial assistance program.

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