Wegovy prior authorization criteria: How to get approved by insurance
Wegovy could be life-changing for your weight loss journey, but insurance companies keep saying no. Before you give up, learn the hidden rules of prior authorization and what to do if you’re denied.
Key highlights
- Most insurance companies require prior authorization before they cover Wegovy. Approval usually depends on meeting BMI thresholds and medical necessity.
- Many plans require proven use of lower-cost or older weight loss medication before Wegovy will be approved, unless your doctor explains why these options are not appropriate.
- Recent BMI records, medical notes, lab results, and a history of weight loss attempts help demonstrate medical need. If coverage is initially denied, appeals and peer-to-peer reviews often succeed when supported by additional evidence.
- Medicare generally does not cover Wegovy for weight management, while Medicaid policies vary from state to state. For those without full coverage, savings programs such as the Wegovy Savings Card or pharmacy discount programs can help reduce out-of-pocket costs.
Has your insurance denied Wegovy? You are not alone. Many patients face this challenge because most insurance companies require prior authorization (PA) before covering Wegovy.
Wegovy (semaglutide) is a GLP-1 receptor agonist approved by the U.S. Food and Drug Administration (FDA) for chronic weight management when used in combination with increased physical activity and a reduced-calorie diet. It is prescribed for adults or children 12 years of age or older with obesity and adults who are overweight with at least one weight-related comorbid condition, such as type 2 diabetes, dyslipidemia, high blood pressure, or sleep apnea. In 2024, the FDA also approved Wegovy to decrease the risk of heart attack (myocardial infarction), stroke, and cardiovascular death in adults with cardiovascular disease, showing that it offers benefits beyond weight loss. The medication is highly effective in reducing the incidence of major adverse cardiovascular events such as heart failure, peripheral arterial disease, and stroke.
The use of Wegovy has increased quickly across the globe. Novo Nordisk, the company that manufactures Wegovy, reported billions in sales in 2025, and prescriptions continue to grow. This rise reflects how widespread obesity has become, now affecting nearly one in eight people worldwide.
The price of Wegovy remains a major hurdle. The retail cost is around $1,349 each month, which adds up to more than $16,000 per year. With such a high cost, insurers demand strong proof that Wegovy is medically necessary before they approve coverage.
This article explains how the prior authorization process works, outlines the criteria for insurance coverage, and provides guidance on how you and your doctor can increase your chances of success.
What is a prior authorization for Wegovy?
Prior authorization, or PA, is approval from your insurance company before they agree to cover Wegovy. Your doctor sends the request with details about your health condition, and the insurance company reviews it before making a decision.
For prior authorization, insurance companies require a valid prescription from a licensed healthcare provider for FDA-approved indications of the medication. Most plans verify your weight, whether you have weight-related conditions like diabetes or high blood pressure, and proof that you have already tried lifestyle changes.
Most requests are reviewed within 3 to 14 days; however, delays may occur if additional information is required.
Wegovy prior authorization criteria
Prior authorization (PA) is the most common requirement before Wegovy is approved by an insurance company. Each plan has slightly different rules, but the areas usually reviewed include:
BMI requirements
BMI (Body Mass Index) is the first measure insurance companies use to decide if Wegovy is appropriate. It reflects weight in relation to height and is used to classify overweight and obesity. You should meet the following criteria as set by the prescribing guidelines:
- A BMI of 30 or higher (obesity) qualifies without other conditions.
- A BMI of 27 or higher (overweight) qualifies if you also have one or more weight-related conditions, such as:
- Hypertension, which increases cardiovascular risk
- Type 2 diabetes, which has been closely linked to excess weight
- High cholesterol, which is known to raise the risk of heart disease
- Sleep apnea, often worsened by obesity
- Cardiovascular disease, such as a previous history of heart attack or stroke
Step therapy rules
Step therapy is a cost-control rule used by many insurers. It means you may have to try older or less expensive weight loss medications before your plan will approve Wegovy. Even other GLP-1 medications like Ozempic, Mounjaro, or Zepbound can come with step therapy requirements unless your doctor explains why they are not appropriate for your condition.
The purpose of step therapy is to show that lower-cost drugs did not provide enough benefit, were poorly tolerated, or were unsafe. With proper documentation, your doctor can make the case that Wegovy is medically necessary for you. Insurance companies require clear, evidence-based proof that Wegovy is the right choice. They often ask for:
- Proof of prior attempts with formulary drugs such as phentermine, Contrave, Qsymia, or metformin.
- Phentermine is an appetite suppressant that is typically used for the short term because of safety concerns in patients with heart conditions.
- Contrave is a combination of bupropion and naltrexone that works on appetite and cravings, but may cause nausea, insomnia, or mood-related side effects.
- Qsymia is a combination of phentermine and topiramate that helps reduce appetite, but can lead to tingling, cognitive changes, or mood issues.
- Metformin is a diabetes medication sometimes used off-label for weight loss, especially in patients with insulin resistance or prediabetes. Insurers may require evidence that it was not effective enough before covering Wegovy.
- A documented step therapy exception request is required if these drugs were contraindicated, such as in patients with cardiovascular disease, severe side effects, or mental health concerns.
Documentation required
A PA is only approved when detailed medical records support the request. Insurance companies typically require:
- Recent body weight and BMI measurements were recorded in a clinic visit, rather than patient self-reports.
- Proof of prior weight loss efforts, which may include logs of diet changes, exercise plans, or structured weight management programs.
- Confirmation of comorbidities, such as laboratory results showing high blood sugar levels, sleep study reports for apnea, or diagnostic codes for cardiovascular disease.
- Medication history, including records of any prior weight loss prescriptions and reasons for stopping them.
How to submit a prior authorization for Wegovy
Submitting a PA for Wegovy is the only way most insurance companies will agree to cover the cost. The process involves cooperation between your doctor and your insurer, with your participation helping to keep things moving smoothly.
1. Get a prescription for Wegovy (semaglutide)
The first step is receiving a prescription from your healthcare provider. A prescription shows that your doctor has determined Wegovy is the right treatment for you based on your health history, BMI, and related conditions. Without a prescription, the PA request cannot be started. Moreover, Wegovy PA cannot be submitted for children below 12 years of age, as the medication is not suitable for them.
2. Complete the prior authorization request form provided by your insurance company
Every insurance company has its own PA form. This form is intended for the insurer to collect evidence that Wegovy is medically necessary for you. Your doctor will need to add your medical data to this form.
Steps for your doctor:
- Fill out the PA request form provided by your insurance company.
- Attach recent office notes showing your BMI and diagnosis.
- Include documentation of past weight-loss methods, such as supervised diet and exercise programs.
- Provide details about any weight loss medications you have tried before and why they were stopped.
Steps for you as the patient:
- Share copies of your health records if your doctor does not already have them.
- Give your provider the contact information for your pharmacy benefits manager (PBM), since this is often required by insurers.
- Confirm that the correct insurer form is being used, as using the wrong one can delay approval.
3. Wait for approval
Once the form and documents are submitted, the insurance company will begin its review. Most insurers issue a decision in about 3 to 14 business days. Some will request more information, which can slow the process. It is important to stay in touch with your doctor’s office and call the insurer yourself to confirm that the request is moving forward.
4. Renew prior authorization
Even if approved, prior authorization is temporary. Most insurers only authorize Wegovy for 6 to 12 months at a time. Your doctor will need to submit new paperwork showing that you are still using the medication and benefiting from it. If renewal paperwork is not submitted on time, coverage may lapse.
Common reasons for prior authorization denial
Even when you meet the medical criteria, Wegovy PA requests can still be denied. Understanding the most common reasons for denial helps you and your doctor prepare a stronger case.
Missing BMI documentation
One of the most frequent issues is incomplete BMI information. Insurers want recent records showing your height, weight, and calculated BMI. Useful actions to fix BMI-related denials include:
- Ask your provider to include updated office visit notes with weight and height
- Make sure BMI is clearly written on the request form
- Provide backup documentation if your insurer asks for it
Paperwork errors
Simple mistakes can delay or block approval. Common paperwork errors include wrong forms, missing details, or unsigned documents. Effective steps to avoid paperwork-related denials include:
- Confirm that the correct insurer form is being used.
- Review the request before submitting it.
- Keep a personal copy of the completed paperwork.
No step therapy attempts
If step therapy is required and not documented, the request will likely be denied. You can follow these steps to avoid request denials:
- Provide a list of previous weight loss medications you have tried.
- Document side effects or reasons the medications were stopped.
- Ensure your provider explains why Wegovy is the most suitable treatment.
Your insurance provider doesn’t believe that Wegovy is medically necessary
Sometimes, insurers believe Wegovy is not essential. Denials based on medical necessity can be overcome with stronger evidence. Strong steps to reinforce medical necessity include:
- Request your doctor to write additional Information and detailed clinical notes supporting your case.
- Submit records of related conditions, such as diabetes or sleep apnea.
- Provide test results or specialist letters to support your appeal.
Your insurance plan doesn’t cover Wegovy
If Wegovy is excluded from your insurance plan, a prior authorization will not help. Visit the Wegovy manufacturer’s website to check if Wegovy is covered by your plan. Practical solutions for coverage exclusions include:
- Verify with your insurer if Wegovy is excluded from the formulary.
- Ask about exceptions in serious medical cases.
- Use manufacturer assistance programs to help lower costs.
Novo Nordisk provides a sample coverage request letter on its website for reference.
How to appeal if your prior authorization request was denied
KFF analysis shows that insurers on HealthCare.gov denied about 1 in 5 in-network claims in 2023. Denial rates were very different from plan to plan, and common reasons included missing prior authorizations, questions about medical necessity, or services not being covered. Additionally, a 2021 survey by the American Medical Association reported that 93% of physicians experienced prior authorization delays, and 30% of them confirmed that their requests were frequently denied.
The good news is that many denials can be overturned. If your request for Wegovy is denied, you have the right to file an appeal. An appeal allows you and your doctor to provide more evidence to your insurance company about why Wegovy is medically necessary.
Writing a strong appeal letter
A well-structured appeal letter should be factual, concise, and supported by documentation. You can make your case stronger by including:
- Your personal details, such as your name, policy number, and contact information
- The denied information, including the date, the medication denied, and the reason the insurer listed
- Your medical history, with BMI records, weight-related health conditions, and previous weight loss attempts
- Treatment evidence, such as details of past prescriptions and why they were discontinued
- A letter of medical necessity provided by your healthcare professional
Templates can make the process easier and help ensure you don’t miss anything important. Resources are available through Novo Nordisk’s Wegovy patient support program, and many insurers also provide templates on their member portals. You can follow these steps to write a strong appeal:
- Review the Novo Nordisk template as a starting point and use it as a foundation.
- Check your insurer’s website for their preferred forms and eligibility criteria.
- Personalize the letter with your own health information and BMI records.
- Ask your provider to attach clinical notes and other supporting documentation.
Does Medicare/Medicaid cover Wegovy?
Wegovy is a costly medication, so many patients ask whether government programs like Medicare or Medicaid will cover it. Medicare generally does not cover Wegovy for weight loss. Federal law excludes weight loss drugs from Medicare Part D, which means patients prescribed Wegovy for obesity management usually have to pay out of pocket.
In 2024, however, the FDA expanded Wegovy’s use to include reducing the risk of complications such as heart attack, stroke, and cardiovascular death in adults who have obesity or are overweight, and heart disease. This new approval opened the door for some Medicare Part D and Medicare Advantage plans to cover Wegovy for cardiovascular risk reduction. Coverage varies by plan, and patients may still incur significant out-of-pocket expenses.
On the other hand, Medicaid coverage is determined by each state. Some states, such as California and Pennsylvania, already include Wegovy on their preferred drug lists. In these states, patients can access Wegovy if they meet BMI and comorbidity requirements and complete prior authorization. Other states continue to exclude Wegovy entirely.
Tips to improve approval odds
Careful preparation makes the difference between a denial and an approval for Wegovy coverage. You can do this by choosing to:
Work with an obesity medicine specialist
Specialists understand the approval process and how to demonstrate medical necessity. They will assess your health conditions before prescribing Wegovy. Afterward, they will write stronger appeal letters and anticipate what insurers require.
Highlight related health issues
Insurance companies are more likely to approve Wegovy if the medication is being used to manage conditions linked to obesity. Ask your provider to include records of issues like prediabetes, sleep apnea, or hypertension in your file.
Request expedited review when appropriate
If your doctor believes waiting could affect your health, you may be eligible for a faster review. Insurers are often required to respond within a few days when urgent health risks are involved. Ask insurers for expedited reviews if urgent.
FAQs about Wegovy PAs
How long does PA approval take?
Most insurers review Wegovy prior authorization requests within 3 to 14 business days. The exact time frame depends on your insurance company, your plan, and whether your provider requested a standard or expedited review. Standard review is more common. Insurers often take one to two weeks to evaluate the paperwork, check eligibility, and make a decision.
Meanwhile, expedited review is available when waiting for a standard decision could put your health at risk. For example, if your provider believes delaying Wegovy could worsen conditions like uncontrolled diabetes or cardiovascular disease, they can request a faster review. In these cases, decisions may be issued in 72 hours or less.
Can I start Wegovy while waiting for PA?
In most cases, you cannot start Wegovy until the PA is approved. Pharmacies are not authorized to dispense the medication unless insurance confirms coverage or you choose to pay out of pocket. You can also explore short-term options, such as:
- Wegovy has a savings card offered by the manufacturer, Novo Nordisk. Some people can pay as little as $0 a month with this program if the medication is covered by their commercial insurance. Those without insurance coverage can pay $499 per month. Medicare and Medicaid patients are not able to use it.
- Pharmacy discount cards can also reduce the cost. These cards can save up to 9 to 27% of the total cost at most U.S. pharmacies. The discounts do not replace insurance, but they can give short-term relief.
- Paying out of pocket for Wegovy is always possible, but very expensive. The list price of a 28-day supply is about $1,349, or roughly $337 per week and $16,188 per year. For most people, this makes long-term use too costly.
What if my PA is denied twice?
A second denial for PA for Wegovy can feel like the end of the road, but it usually is not. There are several steps you can still take to keep fighting for coverage:
- Submit a new appeal with updated documentation
- Use the external review process for another chance
- Get support from a weight management specialist
- Strengthen your case with clinical trial evidence
- Consider other medications or programs if needed
Does Wegovy PA expire?
Wegovy prior authorizations expire and need to be reapproved. Most approvals last six to twelve months, and nearly all plans require an annual renewal. At renewal, your doctor must send updated records such as your current BMI, weight changes, and notes about your progress on Wegovy.
Insurers also want proof that you are continuing healthy lifestyle habits like diet and exercise. Renewal is often easier than the first approval, but starting the process early helps avoid coverage gaps and keeps your treatment moving forward without interruption.
How to save on Wegovy without insurance
The retail price of Wegovy in the United States is around $1,300 per month without insurance. Even with insurance, copays and prior authorizations can make access difficult. Fortunately, there are ways to lower the cost. Two of the most common options are the Wegovy Savings Card and pharmacy discounts.
Wegovy Savings Card
The Wegovy Savings Card is one of the easiest ways to lower the out-of-pocket cost of Wegovy. Offered by Novo Nordisk, the maker of Wegovy, this program helps make treatment more affordable for patients who qualify. You can learn more and apply directly through the official Wegovy Savings Card page.
How it works:
If you have commercial insurance that covers Wegovy, the savings card may reduce your monthly cost to as little as $0. Novo Nordisk covers the remaining cost up to a monthly maximum, and benefits usually last for up to 12 fills in a year. To use the card, you must show it at the pharmacy each time you pick up your prescription.
Individuals without insurance can pay $499 for a one-month supply.
Who is eligible:
- Patients living in the United States with a valid prescription for Wegovy.
- Patients who are not covered by Medicaid, Medicare, TRICARE, or Veterans Affairs insurance
How much does it cost:
- Patients with commercial or private insurance that includes prescription drug benefits for Wegovy can pay as little as $0 per month.
- Patients with commercial insurance that doesn’t cover Wegovy or self-paying patients can pay $499 per month.
To get started:
Getting started is simple. Visit the official Wegovy Savings Card website, enter your personal and insurance information, and download or print your card. Present it at your pharmacy to get Wegovy at discounted prices.
Prescription discount cards
Another way to save on Wegovy is with prescription discount cards. Websites like GoodRx, SingleCare, WellRx, and Optum Perks offer coupons that lower the cash price of semaglutide at many pharmacies.
The process is straightforward. You can search for Wegovy on these websites, print or download a coupon, and present it to the pharmacist. In some cases, you may save up to 27% of the retail price.
These discounts do not replace full insurance coverage but can give temporary relief while you explore other options.
Conclusion: How to increase your chances of insurance coverage for Wegovy
Insurance approval for Wegovy often depends on meeting the right coverage criteria. Most insurers require a BMI of 30 or higher, or 27 with a weight-related problem like diabetes, hypertension, or sleep apnea. Some also require step therapy, which means trying other medications before Wegovy. You should attach your recent BMI records, medical notes, and proof of past weight loss attempts to make a stronger request for prior authorization.
Despite all this, many initial requests are still denied. You can submit an appeal within the required time period. Adding extra medical evidence or asking a specialist to support your case can make a big difference.
If you are denied more than once, your provider can request a peer-to-peer review. This is when your doctor talks directly to the insurance company about your needs. With support from your healthcare team, your chances of approval can drastically improve. Many patients succeed after staying consistent and pushing forward.
Even if you do not have coverage for Wegovy, you can still get Wegovy for $499 per month with the Wegovy Savings Card.
