Is Wegovy Covered by Insurance? Criteria, Copay, Appeal

Does insurance cover Wegovy?

Wegovy coverage by plan

Plan	For weight loss	For type 2 diabetes	Prior authorization
Medicare	Bridge program only	Covered by Part D plans	Required
Medicaid	Varies by state	Covered	Required
Aetna	Employer option	Covered on formulary	Required
Cigna (Evernorth / Express Scripts)	Plan dependent	Covered on formulary	Required
UnitedHealthcare (Optum Rx)	Plan dependent	Covered on formulary	Required
Blue Cross Blue Shield	Plan dependent	Covered on formulary	Required
Kaiser Permanente	Plan dependent	Covered on formulary	Required
CVS Caremark	Plan sponsor choice	Covered on formulary	Required
VA (Veterans Health Administration)	Covered with criteria	Covered	Required
GEHA	Covered with PA	Covered	Required
Ambetter (Centene)	Excluded	Covered on formulary	Required
Express Scripts	Plan sponsor choice	Covered on formulary	Required
Optum Rx	Plan sponsor choice	Covered on formulary	Required
Humana	Bridge program only	Covered by Part D plans	Required
TRICARE	Prime and Select only	Covered with PA	Required
ACA Marketplace plans	Rare	Common	Required
Navitus	Plan sponsor choice	Covered on formulary	Not listed
Amerigroup (Elevance Medicaid)	Follows state Medicaid	Covered with PA	Required

The published policy

• The Medicare Bridge program includes Foundayo, Wegovy, Zepbound KwikPen
• Wegovy tablets are generally excluded by UnitedHealthcare
• Among federal Marketplace drug plans, 1% under ACA Marketplace plans covered Wegovy during 2024
• Medicare Part D can provide coverage for diabetes or cardiovascular disease
• Employer add-on for Cigna: Copay cap add-on with a $200 per month cap
• Blue Cross Blue Shield, Blue Cross Massachusetts (2026): coverage dropped unless the employer keeps it
• Optum Rx, CHAMPVA: no coverage for weight loss
• VA, Criteria updated: April 2026

Sources: humana.com, medicare.gov, CMS, aetna.com.

Prior authorization checklist

Weight-loss prior authorization rules by plan

Plan	Weight rule	Lifestyle program	To keep coverage
Aetna	Baseline: BMI 30 or higher, or BMI 27 or higher when a weight-related condition applies	6 months of a weight program first	5% of baseline weight lost to renew
Cigna (Evernorth / Express Scripts)	BMI 27 or higher with a weight-related condition	Not listed	5% weight loss after 3 months
UnitedHealthcare (Optum Rx)	BMI 27 or higher with a weight-related condition	Not listed	Not listed
Blue Cross Blue Shield	BMI 35 or higher (Horizon NJ) requires a weight-related condition	Not listed	Not listed
VA (Veterans Health Administration)	BMI 27 or higher with a weight-related condition	Not listed	Not listed
Ambetter (Centene)	BMI 27 or higher with established heart disease	Not listed	Not listed

• The chart identifies either the weight diagnosis the plan requests or another approved use of Wegovy: heart risk and MASH liver disease.
• Your BMI comes from the height and weight measured for you.
• Examples of entries in your records for weight-related conditions include high cholesterol or high blood pressure.
• Notes on the diet and activity program you tried

Sources: aetna.com, static.cigna.com, uhcprovider.com, horizonblue.com.

If you are denied: how to appeal

1. Find the denial letter; it identifies the exact unmet rule.
2. Include chart notes that address the rule with the appeal, which your prescriber files
3. Request an independent outside review if the plan's appeal does not succeed

State and plan differences

An insurer may approve coverage in one state or employer plan while denying it in another

• Blue Cross Blue Shield, Blue Cross Massachusetts (2026): coverage dropped unless the employer keeps it
• This exclusion cannot be appealed: Blue Cross Blue Shield, Appeal
• Blue Cross Blue Shield, Horizon (New Jersey) weight rule: BMI 35 or higher (Horizon NJ) requires a weight-related condition
• The rule starts for Blue Cross Blue Shield, Horizon (New Jersey) on January 1, 2026
• The policy date is October 1, 2026 for Blue Cross Blue Shield, Federal Employee Program
• Kaiser Permanente, When it is covered: it depends on the benefit
• Kaiser Permanente, Members without the benefit pay the cash price
• TRICARE, Type 2 diabetes coverage requires PA

Each state sets Medicaid on its own. each state sets its own Medicaid rules. Right now, 10 states cover GLP-1s for weight loss: Wisconsin, Virginia, Tennessee, North Carolina, Missouri, Mississippi, Minnesota, Michigan, Kansas and Delaware. Compare all states.

Sources: bluecrossma.org, horizonblue.com, info.caremark.com, healthy.kaiserpermanente.org.

If coverage says no: other routes

Prices checked November 2026. Each price links to its source page.

Sources: TrumpRx, NovoCare, CMS, medicare.gov.