What do insurers require for Wegovy prior authorization?

Caremark's Wegovy criteria (4774-C) for adults require "The patient is 18 years of age or older." and that "The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy." You then need "a baseline body mass index (BMI) greater than or equal to 30 kg/m2" or "a baseline BMI greater than or equal to 27 kg/m2" with "at least ONE weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)." Each BMI line is tagged "[ACTION REQUIRED: Documentation is required for approval.]" To continue, "The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss." For the adult injection: "Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months". For the tablet: "Initial therapy DOA: 6 months; Continuation of therapy DOA: 12 months".

CVS Caremark, Initial Prior Authorization with Quantity Limit, Wegovy, Weight Loss Management (4774-C) · source

Caremark's Wegovy criteria (4774-C) cover heart-risk use separately. "The patient has established cardiovascular disease with a history of ONE of the following": a previous MI, a previous stroke, symptomatic peripheral arterial disease, or "Prior history of revascularization (coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or angioplasty)." It also requires "The patient has a baseline body mass index (BMI) greater than or equal to 27 kg/m2.", "The patient does NOT have type 2 diabetes.", and that the patient "is currently receiving guideline-directed management and therapy (GDMT) for cardiovascular disease" or has a clinical reason not to be. The request cannot be for "Wegovy HD 7.2 mg (semaglutide) injection." Duration: "Risk reduction of major adverse cardiovascular events: DOA: 12 months".

CVS Caremark, Initial Prior Authorization with Quantity Limit, Wegovy, Weight Loss Management (4774-C) · source

Cigna's Wegovy injection policy IP0814, effective September 1, 2026 (printed as 09/01/2026), says "Prior Authorization is required for benefit coverage of Wegovy injection (Wegovy and Wegovy HD)." For adult weight loss: "Approve for 8 months if the patient meets ALL of the following", including "Patient is ≥ 18 years of age", "Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months", and "At baseline, patient had a BMI ≥ 30 kg/m2" or a BMI of at least 27 with one listed comorbidity. Renewal: "Approve for 1 year" where "Patient has lost ≥ 5% of baseline body weight".

Cigna Healthcare, Drug Coverage Policy IP0814, Wegovy injection, effective September 2026 · source

Cigna's IP0814 heart-risk criteria: "Major Adverse Cardiovascular Event(s) Risk Reduction in a Patient with Established Cardiovascular Disease with Overweight or Obesity. Approve for 1 year" where "Patient is ≥ 18 years of age", "At baseline, patient had a BMI ≥ 27 kg/m2", and the patient has had "a prior myocardial infarction", "Patient has had a prior stroke" or symptomatic peripheral arterial disease. "According to the prescriber, the medication will be used in combination with optimized pharmacotherapy for established cardiovascular disease".

Cigna Healthcare, Drug Coverage Policy IP0814, Wegovy injection, effective September 2026 · source

Cigna's separate policy IP0739, titled for a BMI of 35 and effective April 30, 2026 (printed as 04/30/2026), sets a higher Wegovy bar. Initial therapy is "Approve for 8 months" where "At baseline, patient had a BMI ≥ 35 kg/m2", or a BMI of at least 27 with "at least TWO of the following weight-related comorbidities". Renewal still requires "Patient has lost ≥ 5% of baseline body weight".

Cigna Healthcare, Drug Coverage Policy IP0739, Weight Loss, Glucagon-Like Peptide-1 Agonists BMI ≥ 35, effective April 2026 · source

Cigna's own revision record is what documents the September 2026 restructuring. The Foundayo policy's Revision Details table logs: "Removed Saxenda, liraglutide, Wegovy Tablet, Wegovy Injection and Zepbound. The products were moved to new individual policies," against a review date of 07/09/2026 and an effective date of 09/01/2026. The per-product policies that resulted — for liraglutide, Wegovy injection, Wegovy tablet and Zepbound — each carry an effective date of 09/01/2026 on their face.

Cigna Healthcare, Drug Coverage Policy IP0206, "Foundayo" (Revision Details), effective September 2026 · source

UnitedHealthcare's weight-loss program (2026 P 1114-22, effective 9/1/2026) lists Wegovy for weight loss and also where "Wegovy injection or tablet is being requested for risk reduction of major adverse cardiovascular events with established cardiovascular disease". It requires use "as an adjunct to lifestyle modification (e.g., dietary or caloric restriction, exercise, behavioral support, community-based program)" and a "Body Mass Index (BMI) ≥ 30 kg/m2", or a BMI of at least 27 with "a weight-related comorbidity (e.g., dyslipidemia, hypertension, type 2 diabetes, sleep apnea)". "Wegovy injection or tablet, Wegovy HD: Authorization will be issued for 5 months." Renewal needs "For Wegovy injection or tablet and Wegovy HD weight loss of ≥ 5% of baseline body weight" and "Continuation of lifestyle modification", then runs 12 months.

UnitedHealthcare, Clinical Pharmacy Programs, Prior Authorization/Notification, Plans with Weight Loss/Appetite Suppression Medication Coverage (2026 P 1114-22), effective September 2026 · source

UnitedHealthcare's Wegovy program for plans without weight-loss coverage (2026 P 1445-4, effective 5/1/2026) says "Medications for the purpose of weight loss are typically a benefit exclusion. The program allows for coverage of Wegovy injection or tablet for the cardiovascular risk reduction indication and Wegovy injection for MASH." Initial approval requires "Patient is 45 years of age or older" and "Submission of medical records documenting all the following": a BMI of at least 27 and established cardiovascular disease, shown by "Prior myocardial infarction (MI)", "Prior ischemic or hemorrhagic stroke" or symptomatic peripheral arterial disease. The patient must be on listed heart medicines unless there is a contraindication or intolerance, and must not have a diabetes diagnosis or "New York Heart Association class IV heart failure". "Authorization will be issued for 12 months."

UnitedHealthcare, Clinical Pharmacy Programs, Prior Authorization/Non-Formulary, Wegovy, Cardiovascular Risk Reduction and MASH Only (2026 P 1445-4), effective May 2026 · source

Aetna's policy "Weight Loss (BMI 35) GIP-GLP-1, GLP-1 Agonists PA with Limit 6450-C P08-2025 v8" requires that "The patient has participated in a comprehensive weight management program that encourages behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for at least 6 months prior to using drug therapy." and that "The patient has a baseline body mass index (BMI) greater than or equal to 35". To continue: "The patient has lost at least 5 percent of baseline body weight OR the patient has continued to maintain their initial 5 percent weight loss." Adult Wegovy injection: "Initial therapy DOA: 8 months; Continuation of therapy DOA: 12 months"; for the tablet, "Initial therapy DOA: 6 months". For heart-risk use the patient needs a history of a previous MI, a previous stroke, peripheral arterial disease or revascularization, "a baseline body mass index (BMI) greater than or equal to 27", and "The patient does NOT have type 2 diabetes." with "Risk reduction of major adverse cardiovascular events: DOA: 12 months".

Aetna, Pharmacy Clinical Policy Bulletin, Weight Loss (BMI 35) GIP-GLP-1, GLP-1 Agonists PA with Limit 6450-C, effective April 2026 · source

Kaiser Permanente Northwest's Wegovy criteria ("Effective: 11/05/26") cover weight management "on the prescription drug benefit for 12 months when the following criteria are met", including "BMI greater than or equal to 30 kg/m2 or BMI greater than or equal to 27 kg/m2 AND has at least one of the following comorbid conditions documented", weight and BMI "documented within the last 30 days approximately", and a failed "adequate trial^ to at least two of the following medications or medication combination therapies". Renewal every 12 months needs "Achieved and maintained 5% or greater weight loss after starting semaglutide". For heart risk: "Patient does not have diabetes; AND", "BMI 27 or greater; AND", "Patient is 55 to 74 years of age; AND" and "Patient has a history of STEMI or Type 1 NSTEMI".

Kaiser Permanente Northwest Region, Criteria for semaglutide injectable (Wegovy, Wegovy HD) Coverage, effective November 2026 · source

Express Scripts does not post its weight-loss criteria on its prior authorization page. It says: "Please call us at 800.753.2851 to submit a verbal prior authorization request if you are unable to use Electronic Prior Authorization. Prior Authorization criteria is available upon request." The same page says to use its general request form "if you would like to request a coverage determination (such as a step therapy exception) or if you would like to make an appeal for us to reconsider a coverage decision."

Evernorth / Express Scripts, Prior Authorization Resources · source

The 2026 National Preferred Formulary lists "FOUNDAYO", "liraglutide [INJ]", "WEGOVY HD [INJ]", "WEGOVY PENS [INJ]", "WEGOVY TABLETS" and "ZEPBOUND PEN [INJ]", and states: "THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2026, THROUGH DECEMBER 31, 2026. THIS LIST IS SUBJECT TO CHANGE."

Express Scripts, 2026 Express Scripts National Preferred Formulary (PRMT22157-26), effective July 2026 · source

Optum Rx's January 1, 2027 Premium prior authorization list opens: "Prior authorization (PA) requires your doctor to tell us why you are taking a medication to determine if it will be covered under your pharmacy benefit." If you need the drug right away, it says to "check with your pharmacy to request a short-term supply of 5 days or less. Keep in mind, you will be responsible for the full cost at that time."

Optum Rx, Prior Authorization, Premium Formulary Utilization Management, effective January 2027 · source

Optum's January 2027 Premium prior-authorization list, under Weight Loss, sets quantity limits of "1 tablet per day" for Foundayo and the Wegovy tablet, "4 syringes per 28 days" for Wegovy, Wegovy HD and Zepbound, and "5 syringes per 30 days" for liraglutide.

Optum Rx, Prior Authorization – Premium Formulary Utilization Management, effective January 2027 · source

Novo Nordisk's Wegovy insurance guide tells you to ask your plan: "Can you send me a document with all the criteria I must meet before Wegovy® is covered?" and "What documents do you need my doctor to send?" giving as examples "documents confirming my weight and BMI, current and prior treatments, tests, or lab results." If your plan does not cover it, the guide suggests asking whether your doctor can request "an appeal or exception"; it explains that "This request is called an appeal or exception." If your employer doesn't pay for it: "Ask your benefits or human resources manager to add coverage for Wegovy®."

Novo Nordisk, NovoCare, Wegovy insurance coverage guide (US26NC00145), effective August 2026 · source

NovoCare's prior authorization page for prescribers treating obesity says "CoverMyMeds is a no-cost solution that automates the process providers and pharmacists use for prior authorization requests to help patients access their medication faster." Its coverage check "Integrates with CoverMyMeds." For registered users, "the details you entered in the coverage check will pre-populate into a prior authorization form."

Novo Nordisk, NovoCare: Cost and coverage support for HCPs treating obesity · source

NovoCare's coverage check for prescribers states: "For other FDA-approved indications, including reduction of major adverse cardiovascular (CV) events in adults with established CV disease and either obesity or overweight," Wegovy "is covered through standard Medicare Part D benefits."

Novo Nordisk, NovoCare: Obesity treatment check coverage tool for HCPs · source

UnitedHealthcare describes its weight-loss coverage as something an employer buys rather than something its members have. The program's own background section opens: "This is an optional program that is put in place for clients or businesses that have elected to cover weight loss products with Prior Authorization/Notification."

UnitedHealthcare, Clinical Pharmacy Programs, "Prior Authorization/Notification – Plans with Weight Loss/Appetite Suppression Medication Coverage" (2026 P 1114-22), effective September 2026 · source