Wegovy Insurance Coverage Estimator
Coverage Calculator
Enter your information to estimate your Wegovy coverage eligibility and costs.
Coverage Requirements
To qualify for Wegovy coverage, you typically need:
- BMI 30+ or BMI 27+ with comorbidities
- Documentation of failed lifestyle interventions (6+ months)
- Pre-authorization from your insurance company
- Meeting insurer-specific criteria for medical necessity
When you hear about Wegovy is a prescription medication containing semaglutide, approved to treat chronic obesity, the first question is usually: will my insurance foot the bill? The answer isn’t a simple yes or no - it depends on the type of plan, your medical history, and a few administrative steps.
Key Takeaways
- Wegovy is covered by many private insurers and Medicare under specific conditions.
- Eligibility typically requires a BMI of 30 or 27 with obesity‑related comorbidities.
- Pre‑authorization and proof of medical necessity are almost always required.
- Out‑of‑pocket costs can vary widely - from a few hundred dollars to over $1,000 per month.
- Understanding your policy’s formulary and pharmacy benefit manager (PBM) rules can save you a lot of hassle.
What Exactly Is Wegovy?
Wegovy is the brand name for a higher‑dose formulation of semaglutide, a glucagon‑like peptide‑1 (GLP‑1) agonist. Originally developed for type‑2 diabetes (sold as Ozempic), the drug was FDA‑approved in June 2021 specifically for chronic weight management. It works by mimicking a gut hormone that signals fullness, slowing gastric emptying, and reducing appetite.
How Does Health Insurance Coverage Work for Wegovy?
Insurance is a contract between you and a payer that helps share the cost of medical services. When it comes to prescription drugs, insurers use a formulary - a list of covered medications organized into tiers. Wegovy usually lands in a higher tier because it’s brand‑name and newer, which means higher co‑pay or co‑insurance rates.
Coverage can be broken down into three broad categories:
- Private employer‑based plans - Many large employers have pharmacy benefits that include Wegovy, but only after meeting step therapy (trying lower‑cost alternatives first) and a documented BMI requirement.
- Individual marketplace plans - Under the Affordable Care Act, certain marketplace plans are required to cover obesity treatments deemed “medically necessary,” but the definition varies by state.
- Medicare Part D and Medicare Advantage - Since 2022, Medicare has begun covering GLP‑1 drugs for obesity, but beneficiaries often face a coverage gap (the “donut hole”) and need prior authorization.
Eligibility: Who Can Get Wegovy Covered?
Insurance carriers typically look for two key clinical markers:
- A body‑mass index (BMI) of 30 or higher, or a BMI of 27 with at least one obesity‑related condition such as hypertension, type‑2 diabetes, dyslipidemia, or obstructive sleep apnea.
- Documentation that lifestyle interventions (diet, exercise, counseling) have been attempted for at least six months without sufficient weight loss.
Some insurers also require a visit to a certified weight loss clinic that can provide a detailed treatment plan and monitor progress.
Step‑by‑Step: Getting Pre‑Authorization
Pre‑authorization is the insurance company’s way of confirming that Wegovy is medically necessary. Skipping this step usually results in a denied claim and a surprise bill.
- Consult a qualified prescriber - Typically an endocrinologist, obesity medicine specialist, or a bariatric‑trained primary care physician.
- Gather supporting documentation - Recent BMI measurement, labs showing comorbidities, and a summary of prior weight‑loss attempts.
- Submit the request - The prescriber’s office sends a pre‑auth form to the insurer’s pharmacy benefit manager (PBM). Some insurers use online portals; others require fax.
- Follow up - If the insurer asks for additional info (e.g., a nutritionist’s note), provide it promptly to avoid delays.
- Receive the decision - Approval usually comes within 7‑14 days. If denied, you can appeal with a letter from your doctor highlighting the clinical need.
Cost Breakdown: What to Expect on Your Wallet
The list price for Wegovy in the U.S. is around $1,350 for a 28‑day supply (as of 2025). Insurance can bring that down dramatically, but out‑of‑pocket costs still vary.
| Insurance Type | Coverage Tier | Typical Co‑Pay / Co‑Insurance | Annual Out‑of‑Pocket |
|---|---|---|---|
| Large Employer Plan | Tier 3 (high) | $50‑$150 per month (co‑pay) | $600‑$1,800 |
| Individual Marketplace | Tier 2 (mid) | 20 % co‑insurance | $1,200‑$2,000 |
| Medicare Part D | Specialty tier | $100‑$250 per month after deductible | $1,200‑$3,000 (depends on donut‑hole usage) |
| No Coverage / Self‑Pay | N/A | Full price | $16,200 + possible discounts via manufacturer |
Many manufacturers offer a six‑month starter kit at reduced cost or a patient assistance program for those who meet income criteria. It’s worth asking your prescriber about these options before you sign a prescription.
Common Pitfalls and How to Avoid Them
- Skipping step therapy - Some insurers require you to try older GLP‑1 drugs like liraglutide (Saxenda) first. Get a clear plan from your doctor if you think step therapy isn’t appropriate.
- Missing the BMI threshold - Even a small measurement error can trigger a denial. Verify your BMI with a calibrated scale and height measurement at the clinic.
- Ignoring the appeal window - Most plans give you 30 days to appeal a denial. Submit a detailed letter from your doctor plus supporting labs.
- Not checking the formulary annually - Insurers can move drugs between tiers each year, affecting your cost. Review the latest formulary each renewal period.
Quick Checklist Before Your Next Appointment
- Confirm your current BMI and list any obesity‑related conditions.
- Bring records of diet, exercise, or counseling attempts from the past 6 months.
- Ask your prescriber if they have a pre‑auth template for your insurer.
- Check whether your plan’s formulary lists Wegovy and note the tier.
- Inquire about manufacturer assistance or discount cards.
Frequently Asked Questions
Does Medicare always cover Wegovy?
Medicare Part D began covering GLP‑1 weight‑loss drugs in 2022, but coverage varies by plan. You need prior authorization, and there may be a deductible and co‑insurance. Not all Medicare Advantage plans include Wegovy, so check your specific policy.
Can I use a discount card if I have insurance?
Yes. Discount cards from the manufacturer can lower the list price, but the insurer will still calculate your co‑pay based on the contracted price. It’s best to apply the card after your claim is processed to avoid duplicate discounts.
What if my insurer denies coverage?
Start with an internal appeal - provide your doctor’s letter, recent labs, and proof of failed lifestyle attempts. If the internal appeal fails, you can request an external review by an independent medical reviewer, often at no extra cost.
Do all private insurers cover Wegovy?
Coverage is not universal. Large group plans are more likely to have Wegovy on the formulary, while smaller or high‑deductible plans may exclude it or place it in a specialty tier with higher out‑of‑pocket costs.
How long do I need to stay on Wegovy for insurance to keep covering it?
Most policies require a documented weight loss of at least 5 % of initial body weight before continuing coverage. After that, you’ll need periodic reassessments (often every 12 months) to confirm ongoing medical necessity.
Bottom line: insurance coverage for Wegovy isn’t guaranteed, but with the right documentation, a clear pre‑authorization process, and a bit of persistence, many patients secure benefits that make the drug financially viable. Talk to a qualified weight‑loss clinic, verify your plan’s formulary, and keep thorough records - that’s the fastest route to getting Wegovy on your prescription without an unexpected bill.