Does Kaiser cover Wegovy?

Does Kaiser cover Wegovy (semaglutide)? The short answer is: it depends. Some Kaiser Permanente plans cover Wegovy, while others don't. Read on as we explore how to find out if your Kaiser plan covers Wegovy for weight loss, what's required to secure coverage, and how to save on Wegovy if Kaiser won't cover it.

Kaiser Permanente coverage for Wegovy varies widely depending on the plan. Some Kaiser plans don't cover Wegovy at all. Others cover Wegovy as a Tier 3 drug with strict prior authorization requirements, while others cover it as a Tier 2 drug without prior authorization.(Higher tiers have higher copays and stricter limits.) And, many plans that cover the Wegovy injection won't cover the pill.

If you have a Medicare Part D plan through Kaiser, both injectable and oral Wegovy are covered, along with oral Foundayo (orforglipron) and the Zepbound (tirzepatide) KwikPens. These GLP-1 weight loss medications are covered under a temporary Medicare GLP-1 Bridge program that lasts through December 31, 2027.

See if you qualify

Kaiser coverage rules and criteria for Wegovy

When Kaiser covers Wegovy for weight loss, the coverage criteria can vary by plan. Some plans, such as the Kaiser Permanente California Commercial HMO plan, cover it as a lower-cost Tier 2 drug with no coverage requirements or restrictions. Other Kaiser plans require prior authorization and step therapy before they'll cover Wegovy for weight loss.

Besides weight management, Wegovy is FDA approved to treat other conditions, for which some plans may cover it for qualifying patients. Here's a quick look at the various conditions Kaiser (sometimes) covers for Wegovy and their possible coverage requirements:

Interestingly, despite Kaiser's usually strict coverage requirements for Wegovy, the insurer may cover Wegovy for some off-label conditions, including obstructive sleep apnea (OSA). Currently, the only drug specifically approved by the FDA for treating OSA is Zepbound, another GLP-1 medication.

Sometimes. While some Kaiser plans cover Wegovy without needing prior authorization, others require prior authorization for Wegovy and have strict coverage requirements. Prior authorization is a process where your prescriber provides documentation that confirms you meet Kaiser's coverage requirements for Wegovy. Your Kaiser healthcare provider will complete the process.

Kaiser's prior authorization requirements for Wegovy can vary by plan. If you are taking Wegovy for weight loss, the following conditions may need to be met:

1. Body mass index (BMI) requirements

 Your weight and BMI have been documented in the past 30 days. (You can calculate your BMI here.) You must have either a BMI of 30 or a BMI of 27 or higher and have a weight-related health condition, such as:

• High blood pressure

• Diabetes

• Pre-diabetes

• High cholesterol

• Heart disease

• Heart failure

• Chronic kidney disease

• Non-alcoholic fatty liver disease

• Obstructive sleep apnea

• Knee osteoarthritis

• Polyendocrine metabolic ovarian syndrome (formerly PCOS)

2. Step therapy requirements

You have tried at least two different weight loss pills plus lifestyle changes for three months or longer and have not lost at least 5% of your body weight. These weight loss pills may include:

• Phentermine

• Diethylpropion

• Topiramate

• Qsymia (phentermine/topiramate)

• Contrave (naltrexone/bupropion)

If your prior authorization is approved, Kaiser will cover Wegovy for 12 months. To maintain coverage, some plans may require you to see your Kaiser healthcare provider every four weeks for a monthly weigh-in.

Each year, if you want to keep taking Wegovy, your Kaiser healthcare provider will need to submit a new prior authorization request. This must include your latest BMI and weight loss results on Wegovy showing that you have lost at least 5% of your body weight since starting Wegovy.

Here’s how to check if your Kaiser Permanente plan covers Wegovy:

• Use their online drug pricing tool. Sign in to the Kaiser Permanente website. Once you're signed in, navigate to the Benefits tab to find the drug cost pricing tool. There, you can search for Wegovy to see if it's covered by your plan.

• Review your plan formulary. This is a list of all the drugs that are covered by your plan, along with their associated cost tier and coverage requirements. Visit the Kaiser Permanente website, select your Region from the drop-down at the upper left, and then select your plan from the list below.

• Call the number on your member ID card. This will connect you with a Member Services representative who can explain whether your plan covers Wegovy, the coverage requirements, and how much it will cost.

• Ask your healthcare provider. Kaiser works differently than other insurers. Unlike Cigna or UnitedHealthcare, your care team and insurance all operate under the same Kaiser network. Because of this setup, your healthcare provider can usually check whether Wegovy is covered.

• Use Ro’s free GLP-1 insurance checker. Ro will contact your Kaiser plan on your behalf and then email you with an easy-to-understand explanation of your coverage details .

The cost of Wegovy with Kaiser varies by plan. Some Kaiser plans cover Wegovy as a Tier 2 drug, while others cover it as a Tier 3 drug with a higher copay. And some plans cover it at 50% coinsurance of your plan’s allowance. With a Kaiser Medicare Part D plan, Wegovy costs $50 per month through the temporary GLP-1 Bridge program.

If your Kaiser plan doesn’t cover Wegovy, you may end up paying full price at the pharmacy ($1,349.02). Or, if eligible, you can get Wegovy on Ro for the cash-pay prices of:

• $149–$299 for the Wegovy pill

• $199–$399 for the Wegovy pen*

*Prices reflect a limited-time offer and are subject to change.

Without insurance, Wegovy can cost $1,349.02 at the pharmacy. If you pay cash (and are prescribed), you can get Wegovy on Ro for $149–$299 for the pill or $199–$399* for the pen, depending on dose and form. With insurance and the manufacturer savings offer, you may pay as low as $25 per month. Under the temporary GLP-1 Bridge program, Wegovy costs $50 per month through Medicare Part D for eligible patients.

Some Kaiser plans simply do not cover Wegovy. If you find yourself in this situation, you still have options to get Wegovy for less.

1. Pay out of pocket for Wegovy. You can get Wegovy without insurance. On telehealth platforms such as Ro, you can get Wegovy online. The Wegovy pill costs $149–$299 on Ro and the Wegovy injection costs $199–$399*. At the pharmacy, Wegovy's retail price is $1,349.02 without insurance or coupons.

2. See if your plan covers another weight loss medication. If your Kaiser plan doesn’t cover Wegovy, it’s possible it covers another GLP-1 injection, such as Zepbound (tirzepatide) or Saxenda (liraglutide) or a weight loss pill, such as Qsymia, Contrave, or Xenical (orlistat).

3. Appeal or request a formulary addition. If your Kaiser plan usually covers Wegovy but your coverage request was denied, you can file an appeal (called a "redetermination"). If your plan does not cover Wegovy, you can ask them to add it to your formulary. Note: Kaiser may still deny these requests.

4. See if you qualify for a GLP-1 with another diagnosis. If you have type 2 diabetes, Kaiser may approve coverage for another GLP-1, such as Mounjaro (tirzepatide) or Ozempic (semaglutide), which contains the same active ingredient as Wegovy. Some plans cover GLP-1s for diabetes even if they’re not covered for weight loss.

 5. Switch insurance plans. If it's close to the end of the year, you may want to consider switching insurance plans. Open enrollment typically begins November 1. Just be sure to check that your new insurance covers Wegovy first — although coverage for GLP-1s can change at any time.

*Prices reflect a limited-time offer and are subject to change.

See if you qualify

Similar to other insurance providers, Kaiser Wegovy coverage varies by plan. 

• When Kaiser does cover Wegovy, prior authorization and step therapy may be required (but not always). It may be covered as a Tier 2 or Tier 3 drug.

• Kaiser Medicare Part D plans cover Wegovy under a temporary GLP-1 Bridge program that lasts through December 31, 2027. The copay is $50.

• You can check if Kaiser covers Wegovy by logging into the website, reviewing your drug formulary, calling Member Services, or asking your Kaiser healthcare provider.

• If Kaiser doesn't cover Wegovy, you can still get Wegovy for less on Ro via self-pay, appeal the decision, or see if you qualify for another GLP-1 prescribed for a different diagnosis.