Is Wegovy Covered by Blue Cross Blue Shield?
Yes, but coverage depends on your specific BCBS plan.
Blue Cross Blue Shield (BCBS) may cover Wegovy (semaglutide) for weight loss when certain clinical criteria are met. Coverage requirements and limitations vary by state and BCBS affiliate but generally include:
- BMI of 30 or greater, or BMI of 27 or greater with at least one obesity-related condition such as hypertension, type 2 diabetes, or dyslipidemia.
- Participation in a structured lifestyle intervention program including diet, exercise, and behavioral counseling.
- Documentation that lifestyle modifications alone have not led to sufficient weight loss.
Does Wegovy Require Prior Authorization?
Yes.
Most BCBS plans require prior authorization before covering Wegovy. The request must typically include:
- Verified BMI and weight
- Diagnosis of related health conditions
- Evidence of prior weight management efforts
- Proposed dosing regimen and plan of care
Are There Limits to Wegovy Coverage?
Yes.
BCBS typically imposes specific limits, such as:
- Monthly quantity limits
- Initial approval for 12 weeks to assess treatment response
- Patients must demonstrate at least 5% weight loss at maintenance dose to continue coverage
Can Pediatric Patients Get Coverage for Wegovy?
Possibly.
Wegovy is FDA-approved for adolescents aged 12–17 with obesity. Some BCBS plans may include pediatric coverage, depending on the policy. Prior authorization and medical necessity documentation are usually required.
What Documentation Is Needed?
Your healthcare provider must submit:
- BMI and relevant clinical history
- Treatment history and lifestyle program participation
- Plan for dosage and monitoring
- Statement of medical necessity
What If Coverage Is Denied?
If your request is denied, you may file an appeal with supporting clinical documentation. Additionally, some patients may qualify for manufacturer savings programs or prescription discount options.
Recent Policy Changes
Some BCBS affiliates, including those in Massachusetts and Michigan, have announced upcoming exclusions for Wegovy coverage under certain plan types starting in 2026. However, federal and some large-group plans may still offer access. Coverage policies continue to evolve, so members should regularly review their plan documents.
Where to Find More Information
Visit Blue Cross Blue Shield’s website or contact your local BCBS affiliate to confirm whether Wegovy is covered under your specific health plan.
FAQ:
Does Blue Cross Blue Shield cover Wegovy for weight loss?
Coverage varies by state and plan. Some Blue Cross Blue Shield plans do cover Wegovy when it is prescribed for chronic weight management and meets specific medical necessity criteria.
Do I need prior authorization from BCBS to get Wegovy?
Yes, most BCBS plans require prior authorization for Wegovy. Your doctor must submit documentation showing a qualifying BMI and diagnosis such as obesity or weight-related comorbidities.
Is Wegovy covered by Blue Cross Blue Shield in all states?
No. Coverage for Wegovy through Blue Cross Blue Shield differs by state and regional provider. It’s important to contact your specific BCBS plan or pharmacy benefit manager to confirm.
What diagnosis is required for BCBS to cover semaglutide?
Most plans require a diagnosis of obesity (BMI ≥30) or overweight (BMI ≥27) with a weight-related condition like type 2 diabetes, hypertension, or high cholesterol.
How do I check if Wegovy is covered by my specific BCBS plan?
You can check your coverage by logging into your Blue Cross Blue Shield member portal or by calling the customer service number on your insurance card. Ask about drug coverage, prior authorization, and formulary tier.