How to get prior authorization for Wegovy

While some prescription drugs are automatically covered by insurance plans, others are not. Sometimes, insurance companies require prior authorization before they’ll cover a certain drug. This process enables them to ensure the drug is medically necessary and is being prescribed safely.

Wegovy (semaglutide) is one of these drugs. And considering it costs $1,349.02 for a 28-day supply if you pay cash, it’s definitely worth trying to get insurance coverage for Wegovy. Read on as we explain the Wegovy prior authorization criteria so you know what to expect when you contact your insurance company.

The best way to know if your insurance plan requires prior authorization for Wegovy is to review your policy documents and contact your insurance company (there’s a number on the back of your insurance card). They’ll let you know if it’s covered or if prior authorization is required. (If it’s not covered at all, this process does not apply to you, and you’ll need to pay out-of-pocket for Wegovy.) 

If you need prior authorization for Wegovy, here are the steps you’ll need to take.

1. Get a prescription for Wegovy

First, you’ll need to meet with a licensed healthcare provider to see if a prescription for Wegovy is right for you. During your appointment, your healthcare provider will check if you meet the FDA-approved eligibility criteria to take Wegovy. Wegovy is FDA-approved for two indications:

1. Weight loss in people with obesity and overweight

2. Cardiovascular risk reduction in people with heart disease and obesity or overweight

To get Wegovy for weight loss, you must fall into one of the following categories:

• Adults with a body mass index (BMI) of 30 or above (defined as obesity)

• Adults with a BMI of 27 or higher (defined as overweight) and a weight-related health condition, such as type 2 diabetes, high blood pressure, high cholesterol, or sleep apnea

• Children ages 12 and up with obesity, defined in children as having a BMI in the 95th percentile (or higher) for their age and sex

To take Wegovy to reduce your cardiovascular risk, you must have heart disease and either obesity or overweight (using the BMI definitions above).

If you don’t meet these eligibility criteria, your healthcare providers can still prescribe Wegovy if they think it’s the best treatment option for you. But, if your insurance plan requires prior authorization for Wegovy, you’ll need to meet these eligibility criteria to be considered for coverage. 

2. Complete prior authorization request form

Prior authorization sounds serious, but it’s actually just a short 1–2 page piece of paperwork. It’s likely your healthcare provider has experience completing these forms for their patients for a variety of drugs, so they’re already familiar with the process and can tell you what (if anything) is needed from you. 

Your healthcare provider or their staff will complete the form on your behalf. Typically, you’ll need to share some information with them to include on the prior authorization form, such as your contact information and date of birth. The form may also ask for additional information, such as:

• The healthcare provider’s contact information

• What you will be taking Wegovy for (weight loss or cardiovascular risk reduction)

• Your prescribed dosage of Wegovy

• Your history with weight loss or other medications you’ve tried (this shows that Wegovy is medically justified, as other, cheaper alternatives are not effective or appropriate)

• Your plan to make other lifestyle changes (such as diet and exercise) while taking Wegovy 

Your healthcare provider may get everything they need during your appointment to complete this form. If any other information is needed, their staff may follow up with you. 

3. Wait for approval

Once your healthcare provider completes the prior authorization form, they’ll submit it to your insurance company to request approval. The appropriate department at your insurance company will review the form and decide whether or not to grant prior authorization. This can happen quickly or slowly, depending on your plan. Usually, it can take a few business days to a few weeks. You can contact your insurance company to check the status of your request.

If approved, Wegovy will be covered according to your plan’s coverage details. Let your pharmacy know about the approval so they can resubmit your claim and fill your prescription. If denied, you have a few options. You can choose to pay out-of-pocket for Wegovy, or you can ask your healthcare provider about other Wegovy alternatives that could be a good fit for you. Or, you can have your healthcare provider submit an appeal to your insurance company (more on this in a later section). 

4. Renew your prior authorization (if applicable)

If you get approved for Wegovy, it’s time to fill your prescription and start treatment. When you have a moment, you’ll want to check how long the prior authorization approval lasts. Sometimes, the coverage will only be for a certain period of time, usually six months or a year. When that period ends, you'll need to get your prior authorization reapproved. 

The reapproval process is similar to the initial paperwork, but you may need to answer additional Wegovy prior authorization criteria  such as documenting how much weight you lost since starting Wegovy, and sharing details of the lifestyle changes you’ve made, including diet and exercise.

It depends on the insurance company. Some insurance plans approve or deny the request almost immediately, while others can take several days to weeks to respond. For example, Blue Shield of California promises a decision within 24 to 72 hours, while Aetna says it can take up to 14 days. You can usually check the status of your request by calling your insurance company or logging into the member website. 

Prior authorization is not a guarantee of insurance coverage. If approved, your medication will be covered according to your plan’s copay or deductible structure. But, insurance companies can choose not to cover Wegovy. In fact, more than one in four prior authorizations are initially denied, according to an American Medical Association survey of 1,000 practicing physicians. Fortunately, a vast majority of appeals (83%) are successful in getting prior authorization approved, according to a separate review of Medicare Advantage plans. 

So, it’s worth asking your healthcare provider to submit an appeal to your insurance company to get Wegovy covered. When appealing your prior authorization denial, make sure that any reasons it was denied are addressed in the new request. We’ll get into those reasons in the next section.

Prior authorization can be denied for a number of reasons, including:

• You haven’t tried other, lower-cost medications for weight loss first. Some insurance plans will only cover Wegovy after you have already tried another, cheaper weight loss medication without success. Your healthcare provider can list the other medications you have tried on the prior authorization form.

• Your insurance plan does not believe that Wegovy is a medically necessary treatment for you. It is important that your healthcare provider demonstrate that you meet the BMI criteria for Wegovy. If your BMI puts you in the overweight category but not obesity, you may need to have another weight-related medical condition, such as high blood pressure, to qualify for Wegovy.

• The form contained paperwork errors. If the prior authorization form is not completed in its entirety or is filled out incorrectly, your prior authorization for Wegovy could be denied.

• Your plan doesn’t cover Wegovy. Some plans simply do not cover Wegovy or other weight loss drugs. Medicare, for example, does not cover weight loss medications, and Medicaid coverage can vary by state. They may cover other medications for weight loss, though. If your prior authorization for Wegovy is denied for this reason, ask your insurance company for a list of the covered alternatives. You can share this list with your provider and see if they think one of these medications could be a good fit for you.

You can still use Wegovy for weight loss without insurance coverage, although you’ll likely have to pay more. But, it’s possible to get Wegovy without paying full price. For example, if you have commercial or private insurance — even if it doesn’t include coverage for Wegovy — you may be eligible for the Wegovy Savings Card, which lowers the out-of-pocket cost for Wegovy to $650 (about half off the list price).

You can also use a pharmacy discount card for Wegovy. You can find these on websites like GoodRx, Optum Perks, and SingleCare. Enter your dosage of Wegovy and your zip code, and the site will show you the discounted price at various pharmacies. Then, you can select a pharmacy and print out your Wegovy coupon.

Compounded semaglutide is another option, which is a version of Wegovy made by a compounding pharmacy. These pharmacies make custom formulations of medications to meet a specific patient’s needs or to help with supply during a drug shortage. They are often more affordable than FDA-approved drugs. Ro offers compounded semaglutide delivered to your door if you qualify. 

However, compounded drugs are not FDA-regulated the way other medications are, so you’ll want to talk to your healthcare provider about whether compounded semaglutide is a good treatment option for you. If it is, make sure the pharmacy you get it from is based in the United States, has a pharmacist on staff, and requires a valid prescription from a licensed healthcare provider.

Bottom line: If you are seeking insurance coverage for Wegovy, prior authorization is usually required. Work with your healthcare provider to submit the necessary paperwork, and, if necessary, an appeal. If your coverage is ultimately denied, you can still get Wegovy more affordably by taking advantage of savings programs and pharmacy discount cards, or using compounded semaglutide.

---

How we reviewed this article

Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

Editorial Guidelines | Medical Review Process

Current version

October 23, 2024

Written by

Amelia Willson

Fact checked by

Patricia Weiser, PharmD

---

About the medical reviewer

Patricia Weiser, PharmD

Patricia Weiser, PharmD, is a licensed pharmacist, health content writer, and medical reviewer with more than a decade of clinical experience in community and hospital pharmacy.