Does Fidelis cover Wegovy?

If you’re interested in taking Wegovy for weight loss, insurance coverage can make a big difference in what you pay. But, does Fidelis cover Wegovy? Based on its current formularies, Wegovy doesn’t appear to be routinely covered.

Still, there may be ways to get it covered. And your chances of getting it covered might depend on what you’re taking Wegovy (semaglutide) for. Here’s what you should know about Fidelis coverage for Wegovy, how to check your benefits, and what to do if it isn’t covered.

No — based on Fidelis’s current formularies, Wegovy is not routinely covered. It isn’t listed on the formularies for Essential Plan, Qualified Health Plans, Child Health Plus, or Wellcare by Fidelis Care Medicare and Dual Advantage plans. Depending on your plan and why Wegovy is prescribed, though, you may be able to request an exception.

Medicaid Managed Care and HealthierLife (HARP) work a little differently. These plans provide prescription drug benefits throughNew York’s NYRx Medicaid pharmacy program rather than directly through Fidelis. That said, NYRx does not currently cover Wegovy for weight loss.

Check your coverage for FDA-approved GLP-1s—for free

Check for free

Fidelis coverage for Wegovy: rules and criteria 

Although Wegovy isn’t routinely covered by Fidelis, you may still be able to get it covered in some cases. A few factors can affect your options, including:

• Your plan type. Different Fidelis plans follow different prescription drug formularies and coverage rules. For example, Medicaid Managed Care and HARP members get pharmacy benefits throughNYRx, which excludes Wegovy when used specifically for weight loss. Other Fidelis plans use their own formularies, some of which may also exclude weight-loss medications.

• Why you’re taking Wegovy. Wegovy has several uses approved by the US Food and Drug Administration (FDA), and they vary between the injection and tablet. Your plan may agree to cover Wegovy for one use but not another, so why your provider prescribes it can affect whether your plan will pay for it.

  • The Wegovy injection is approved for chronic weight management in certain adults and adolescents, reducing cardiovascular risk in certain adults, and treating certain adults with noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH), a serious form of fatty liver disease.

  • Wegovy tablets are approved for chronic weight management and reducing cardiovascular risk in certain adults.

• Whether you meet your plan’s requirements. If your plan agrees to cover Wegovy, you’ll also need prior authorization. That means your provider must submit information showing that you qualify for Wegovy and that it’s medically necessary.

Yes, Fidelis requires prior authorization for all GLP-1 medications, including Wegovy. Your healthcare provider handles this process by submitting information that shows why Wegovy is necessary and appropriate for you. This information may include:

• Your diagnosis and the reason you’re being prescribed Wegovy

• Relevant details from your medical history, such as your weight, body mass index (BMI), or related health conditions

• Treatments or medications you’ve already tried and how well they worked

Fidelis will review the request and decide whether you qualify for coverage. If it’s approved, your plan will help pay for Wegovy based on your benefits. If it’s denied, you may be able to appeal or look into other ways to get the medication (more on those below).

For Fidelis Care members enrolled in Medicaid Managed Care or HARP, prescription drug coverage is handled through New York’s Medicaid pharmacy program (NYRx). While GLP-1 drugs aren’t covered for weight loss alone, NYRx may cover Wegovy for cardiovascular risk reduction in people who meet all of the following prior auth requirements:

• You must have a confirmed diagnosis of cardiovascular disease.

• Your BMI must be 40 kg/m² or greater.

• You must be participating in lifestyle changes that support cardiovascular health.

If approved, coverage is limited to two Wegovy treatment attempts over your lifetime, according to NYRx.

Although Wegovy doesn’t appear on the current Fidelis formularies, it’s still worth confirming your benefits. Coverage can change, and your plan may have a process for requesting an exception. Here are a few ways to check:

• Check your plan’s formulary. Look up your plan’s current list of covered medications and search for Wegovy or its active ingredient, semaglutide. Just note that semaglutide is also the active ingredient in Ozempic, a different medication that’s FDA-approved for type 2 diabetes rather than chronic weight management.

• Call Fidelis. Use the Member Services number on your insurance card to ask whether your plan covers Wegovy and what requirements you’ll need to meet.

• Ask your healthcare provider. Your provider’s office may be able to check your benefits and, if Wegovy requires prior authorization, submit the necessary paperwork on your behalf.

• Check through Ro. Use Ro’s free GLP-1 Insurance Coverage Checker to see whether your insurance may cover the Wegovy pen or pill (or certain other GLP-1 medications).

Without insurance, both the Wegovy injection and tablets have a list price of $1,349.02 per package, but that’s not necessarily what you’ll pay. Novo Nordisk currently offers lower self-pay prices through its savings program and NovoCare Pharmacy.

For eligible self-paying patients, current prices (as of the time of this writing) are as follows:

• Wegovy pills: $149 per month for 1.5 mg, $199 for 4 mg, or $299 for 9 mg or 25 mg.

• Wegovy injection: $349 per month for the 0.25 mg through 2.4 mg doses, and $399 per month for the Wegovy HD pen (a higher-strength 7.2-mg version of the medication). New patients may qualify for a limited-time price of $199 per month for their first two fills of the 0.25 mg or 0.5 mg doses. 

If you have other commercial insurance that covers Wegovy, you may also qualify for a manufacturer savings offer that can bring your cost down to as low as $25 per month (though government insurance beneficiaries aren’t eligible for this offer).

If Wegovy is still out of reach, it may be worth exploring other GLP-1 medications. Ro’s free GLP-1 Insurance Coverage Checker can help you find out whether your plan covers other options, while Ro also offers cash-pay GLP-1 treatments for eligible patients.

If Fidelis won’t cover Wegovy, you still have a few options. Depending on your plan and why you’re taking the medication, you can:

• Ask for a formulary exception. Since Wegovy isn’t listed on the current Fidelis formularies reviewed, your provider may be able to request an exception. They’ll typically need to provide medical information explaining why Wegovy is necessary for you (for instance, why any covered alternatives aren’t appropriate). 

• Appeal a denial. If Fidelis denies a request to cover Wegovy, you can ask the plan to reconsider its decision. Your provider may be able to submit additional medical information to support the appeal. 

• Ask about another GLP-1. Talk to your healthcare provider about whether another GLP-1 medication could be appropriate for you and covered by your plan. If you have type 2 diabetes, Fidelis may cover other options such as Ozempic or Mounjaro (tirzepatide).

• Consider paying cash. If insurance coverage isn’t an option, you can pay out of pocket for Wegovy. Manufacturer self-pay programs and cash-pay options through Ro may bring the cost below the medication’s list price.

See if you qualify

Wegovy doesn’t appear on the current Fidelis formularies, meaning it isn’t routinely covered. Here’s the big picture:

• Fidelis Medicaid Managed Care and HARP members get pharmacy benefits through NYRx, which does not currently cover Wegovy for weight loss but may cover it for certain people with cardiovascular disease.

• Wegovy has several FDA-approved uses, and why it’s prescribed may affect your coverage options.

• If Wegovy isn’t on your plan’s formulary, you may be able to request an exception. If your coverage request is denied, you may also have the option to appeal.

• If insurance won’t cover Wegovy, manufacturer savings programs, cash-pay options, or another covered GLP-1 may help make treatment more affordable.