Semaglutide Eligibility: BMI, Diagnosis
Semaglutide is FDA approved for heart risk and type 2 diabetes; kidney disease in people who have type 2 diabetes; you qualify when your diagnosis matches one of those uses. Health plans then add their own rules before they pay. In STEP 1, people on Wegovy lost 14.9% of body weight on average, vs 2.4% on placebo.
- Brands
- Ozempic, Wegovy and Rybelsus
- Best result (STEP 1)
- 14.9% weight loss
Wegovy overview
Its half-life is about 1 week. After 7 d, half is gone, and after five half-lives (35 d), about 3% remains.
In STEP 1, people lost 14.9% of body weight over 68 weeks, compared with 2.4% on placebo.
Monthly price points in US dollars include list price and self-pay offers. Each comes from the maker's price page.
Sources: FDA label (DailyMed), healthsystemtracker.org, prnewswire.com 1 2.
Who qualifies?
| Who sets the rule | Who qualifies |
|---|---|
 Ozempic | Alongside diet and exercise, it lowers blood sugar in adults with type 2 diabetes. |
| Ozempic | Adults with type 2 diabetes and heart disease: it lowers the chance of heart attack, stroke, and heart-related death. |
| Ozempic | In adults with type 2 diabetes who also have chronic kidney disease, it lowers the risk of worsening kidney disease, kidney failure, and death related to the heart. |
 Wegovy | For adults with heart disease who also have obesity or overweight, it lowers the risk of heart attack, stroke, and heart-related death (injection and tablets). |
| Wegovy | With diet and activity, it supports long term weight loss and keeping weight off. This applies to adults and children 12 and older with obesity, and to adults with overweight and a weight-related condition. |
| Wegovy | For adults, it treats MASH liver disease with moderate to advanced scarring (no cirrhosis) (injection). |
| Wegovy | For adults, the tablets are approved for weight loss and heart risk. |
 Rybelsus | Alongside diet and exercise, it lowers blood sugar in adults with type 2 diabetes. |
| Rybelsus | For adults at high risk who have type 2 diabetes, it lowers the chance of heart attack, stroke, and heart-related death. |
| Medicare GLP-1 Bridge | BMI 35 or higher, no condition needed |
| Medicare GLP-1 Bridge | A BMI of 30 or higher, plus heart failure, uncontrolled blood pressure, or CKD 3a+ |
| Medicare GLP-1 Bridge | A BMI of 27 or more, plus Prediabetes, an earlier heart attack or stroke, or PAD |
| Typical commercial plan (Aetna policy) | BMI 30 or higher |
| Typical commercial plan (Aetna policy) | BMI 27 or higher with a weight-related condition |
| Typical commercial plan (Aetna policy) | a diet and activity program comes first, for 6 months |
Sources: FDA label (DailyMed) 1 2 3, medicare.gov 1 2, aetna.com.
Trial results for weight loss
| Trial | Medicine | Who took part | Length | People | Main result | Comparison |
|---|---|---|---|---|---|---|
| STEP 1 | Wegovy | Adults with obesity or overweight, without diabetes | 68 weeks | 1,961 | 14.9% weight loss | 2.4% on placebo |
| OASIS 4 | Wegovy | Adults with obesity or overweight, without diabetes | 64 weeks | 307 | 13.6% weight loss | 2.4% on placebo |
Source for this trial: STEP 1 (FDA label (DailyMed)).
What are the changes for weight loss?
| What changes | What the label says | Labels |
|---|---|---|
| Risk of Thyroid C-Cell Tumors | It caused thyroid C-cell tumors in rodents, but it is not known whether it causes them in people. Do not use it if you or your family has a history of medullary thyroid cancer (MTC), or if you have MEN 2. | All of them |
These details come from the FDA labels: FDA DailyMed label.
These warnings come from the FDA label (DailyMed).
Coverage for weight loss
A GLP-1 used only for weight loss is not covered by Medicare Part D.
If you meet the rules of the Medicare GLP-1 Bridge, the program lists Wegovy at $50 each month.
Medicaid plans that cover GLP-1s for weight loss usually require prior authorization.
Sources: humana.com, CMS, KFF.
- Semaglutide Cost Without Insurance
- Semaglutide Coupons
- Semaglutide Insurance Coverage
- Does Medicaid Cover Semaglutide? Wegovy and Ozempic by State
- Does Blue Cross Blue Shield Cover Semaglutide? Criteria, Copay
- Does UnitedHealthcare Cover Semaglutide? Criteria, Copay, Appeals
- Ozempic Coupon
- Ozempic Cost
- Ozempic Cost Without Insurance
Other options for weight loss
| Medicine | For eligibility | How it is taken | Trial result |
|---|---|---|---|
| Ozempic | Heart risk and type 2 diabetes; kidney disease in people who have type 2 diabetes | weekly injection | Not listed |
| Wegovy | Weight loss, heart risk and MASH liver disease | weekly injection or daily tablet | 14.9% weight loss |
| Rybelsus | Type 2 diabetes and heart risk | daily tablet | Not listed |
 Mounjaro | Type 2 diabetes and heart risk | weekly injection | Not listed |
 Zepbound | Weight loss and sleep apnea | weekly injection | 20.9% weight loss |
 Foundayo | Weight loss | daily tablet | 11.1% weight loss |
 Trulicity | Type 2 diabetes and heart risk | weekly injection | Not listed |
 Saxenda | Weight loss | daily injection | 7.4% weight loss |
 Victoza | Type 2 diabetes and heart risk | daily injection | Not listed |
| Byetta | Type 2 diabetes | twice-daily injection | Not listed |
Sources: FDA label (DailyMed).
Questions to ask your prescriber
- Does the label rule for this medicine apply to me?
- What will my plan ask for before it pays?
- Which brand fits the diagnosis I have?