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An insurance card and a stethoscope: How to get Wegovy covered by insurance
Drug Info

How to get Wegovy covered by insurance

Insurance plans vary widely in regard to how they cover weight loss medication
Nadine Woloshin headshot
By | Mar. 21, 2024 Medically reviewed by Karen Berger, Pharm.D. & Scott Dershowitz, LMSW, CMC
In this article:

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.

Wegovy coupons

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.” 

 

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